CENTRAL CASE NUMBER
EPID Number filled at district Form A To be filled at NCDC
COV-IND-___ _____ ___ _______ NATIONAL CENTRE FOR DISEASE CONTROL
(To be filled COVID-19 Acute Respiratory Disease)
A PATIENT INFORMATION
1. Name of patient: Age: ____yr ____mo (___/___/_____) Date of interview:
Gender: M/F
2. Name of Health Facility where District (Isolation facility): State (Isolation facility):
isolated:
3. Name of interviewer Designation of interviewer: Contact Number of interviewer:
4. Case Classification: Confirmed Suspect
5.
Current status of case: Stable □ Admitted in ICU □ Deceased □
B SOCIODEMOGRAPHC PROFILE
Nationality: Indian Non-Indian (Name of country) …………………………………..
Father’s name: House No. Setting: Rural / Urban
Village/Mohalla: District: Phone number:
Block: State: email id:
C CLINICAL INFORMATION
1 Patient clinical course
1.1 Date of Onset of symptoms: ____ /_____ / ________; Initial Symptoms:
1.2 Details of contact with heath facility after the date of onset
Name of facility: 1 2 3 4
Address:
Phone number:
Dates case visited:
Did health facility Yes/No Yes/No Yes/No Yes/No
report the case
1.3 Date of admission in isolation facility:
1.4 Outcome (encircle): Under treatment/ Discharged/ LAMA/ Died 1.5Date of outcome (if applicable)___/___/______
1.6 Cause of death (As mentioned in death certificate):
2 Patient Symptoms at admission (encircle all reported)
a) Fever/chills b) Sore throat c) Nausea/Vomiting
d) General weakness e) Breathlessness f) Headache
g) Cough h) Diarrhea i) Irritability/confusion
j) Runny nose k) Pain(encircle): muscular, chest, l) Any other(specify)
abdominal, joint
3 Patient signs at admission: Details of following Signs to be taken from the case sheet if the patient is admitted
a) Temperature (in Fahrenheit): b) Abnormal Lung X-Ray /CT scan c) Coma: Yes / No
findings: Yes / No
d) Stridor: Yes / No e) Tachypnoea: Yes / No f) Seizure: Yes / No
g) Redness of eyes: Yes / No h) Abnormal lung auscultation: Yes/ No i) Any other(specify):
4 Underlying medical conditions (encircle all that apply)
a) COPD b) Hypertension c) Chronic neurological or
neuromuscular disease
d) Chronic Renal Disease e) Asthma f) Heart disease
g) Bronchitis h) Pregnancy i) Immunocompromised condition
(trimester) including HIV, TB
j) Malignancy k) Post-partum (< 6 weeks) l) Any other(mention)
m) Diabetes n) Liver Disease o) None
D EXPOSURE HISTORY
5 Occupation (circle): Student/ Businessman/ Health care worker/Health care lab worker/ animal handler/ any other
(specify)………………………
6 H/O contact with COVID-19 case (encircle): Lab confirmed case of COVID-19 / Suspect case under investigation / No
contact / Not known; (If contact with Lab confirmed case, mention its EPID number: COV-IND-____ _____ ____ ________)
6.1 If contact is with lab confirmed COVID-19 case, then mention contact setting (encircle all that apply)
a) While taking samples/ other b) Visit to a place where COVID-19 :
investigations cases are treated/ sampled (specify
c) Clinical care of case (among d) Immigration Staff at Point of Entry e) Housekeeping (Hospital)
HCW) (details of place)
f) Caregiver of the case (specify g) Living in the same household h) Providing services to the household
details of case)
i) Living in the neighborhood j) Others, Specify
7 Is patient a member of a cluster of patients with severe acute respiratory illness (e.g., fever and pneumonia requiring
hospitalization) or COVID 19? Yes/No
8 Patient attended festival or mass gathering in last 1 month? (Yes/No/Unknown) if yes, specify:
E TRAVEL HISTORY
9 Have you travelled outside India in the past one month? Yes/ No. If yes, then fill details in Q. 9.1 onwards else skip to Q.10
9.1
Name of the country (City) Date of arrival Date of departure
9.2 Did you visit Wuhan (yes/no) During your stay, did you visit any animal market? Yes/No
9.3 Date of arrival in India (Including transit flights in India): ____/_____/____ Flight No: Seat No:
10 Have you travelled within India in the past one month? Yes/ No. If no, skip to Section F
If yes, details of places visited in chronological order; flight / train / vehicle number; seat/berth, coach number etc
a) Place & Duration of stay: Date of arrival: Mode of travel:
Date of departure: Details:
b) Place & Duration of stay: Date of arrival: Mode of travel:
Date of departure: Details:
c) Place & Duration of stay: Date of arrival: Mode of travel:
Date of departure: Details:
F LABORATORY INFORMATION (to be obtained from treating physician/DSO)
11 Sample collected for confirmation of COVID-19 case: Yes / No, if Yes, fill the details and update the results
a) Type of Name of sample Date of sample Sent to which Result Date of
sample collection center collection Lab (Positive/Negative) lab result
collected
Reason if sample not collected:
b) Name of lab that confirmed result:
G CLINICAL COURSE (Complication) Encircle where applicable
12a) Hospitalization: Yes / No Date of hospitalization:
b) ICU Admission: Yes / No Date of ICU admission: Date of discharge from ICU:
Mechanical Ventilation: Yes / No Date of mechanical ventilation Start:
Date of mechanical ventilation Stop:
ARDS: Yes / No Cardiac failure: Yes / No
Pneumonia by Chest X ray: Yes / No Acute Renal Failure: Yes / No
Consumptive coagulopathy: Yes / No Other complication: Yes / No, if yes please specify:
H PUBLIC HEALTH RESPONSE
a) Total no. of high risk contacts: _____ ; No. of high risk contacts traced:_______;
No. of samples collected in high risk contacts: ______ ; No. of high risk contacts developed symptoms ________;
No. of high risk contacts tested positive:_______
b) Total no. of low risk contacts: ______ No. of low risk contacts become symptomatic: ______
No. of low risk contacts tested:______ No. of low risk contacts tested positive:______
