Homeless Symptom Follow-Up

DRAFT

Form Approved: OMB: 0920-XXXX Exp. XX/XX/XXXX

Version 7 February 20

Human Infection with 2019 Novel Coronavirus (2019-nCoV)

Homeless Study Follow-up Investigation Form

State: ______________ Source Case state/local ID: ______________

State/local health dept.: ______________ Source Case CDC 2019-nCoV ID ^b: ______________

Contact ID ^a: ______________ Contact 2019-nCoV ID^c: ______________

1. Assign Contact ID using CDC 2019-nCoV ID and sequential contact ID, e.g., Confirmed case 0023CA has contacts 0023CA-001 and 0023CA-002

2. Complete with ID of the associated confirmed case who identified this contact

3. To be assigned at CDC

Interviewer instructions: prior to interview with contact, please note the following information about the confirmed 2019-nCoV case that identified this contact:

……………PATIENT IDENTIFIER INFORMATION IS NOT TRANSMITTED TO CDC……………………

Name:_________________________________

……………PATIENT IDENTIFIER INFORMATION IS NOT TRANSMITTED TO CDC……………………

Case Identification number____________________________________________________

Demographic information

1. Date of birth (MM/DD/YYYY): / /

2. Age: _______ years months

3. Current residence: Country: _________ State:______________County___________City______________

4. Ethnicity: Hispanic or Latino Not Hispanic or Latino

5. Race: White Asian American Indian/Alaska Native Black or African American Native Hawaiian/Other Pacific Islander

6. Sex: Male Female

Symptoms

7. In the past day, have you experienced any of the following symptoms?

Symptom	Symptom Present?	Duration (no. of days)
Systemic
Fever >100.4F (38C)	Yes No Unk
Subjective fever (felt feverish)	Yes No Unk
Cough (new onset or worsening of chronic cough)	Yes No Unk
Shortness of breath (dyspnea)	Yes No Unk
Vomiting	Yes No Unk
Nausea	Yes No Unk
Diarrhea (≥3 loose/looser than normal stools/24hr period)	Yes No Unk

Medical History

8. Do you have any of the following:

Chronic Lung Disease	Yes	No	Unknown	Specify:
Smoking	Yes, current	Yes, former	No	Unknown
Active tuberculosis	Yes	No	Unknown
Diabetes Mellitus	Yes	No	Unknown	Specify:
Cardiovascular disease	Yes	No	Unknown	Specify:
Renal disease	Yes	No	Unknown	Specify:
Liver disease	Yes	No	Unknown	Specify:
Immunocompromised Condition	Yes	No	Unknown	Specify:
Neurologic/neurodevelopmental disorder	Yes	No	Unknown	Specify:
Other chronic diseases	Yes	No	Unknown	Specify:

Social History

1. Have you been to a shelter in the last 2 weeks (14 days) before your symptoms started or your test was positive? (Any of the symptoms listed above)

If yes, name of shelters where you have slept? ______________________________________

If not in shelters, where have you slept? ___________________________________________

2. Where have you eaten your meals in the last 2 weeks (14 days) before your symptoms started or your test was positive?

Names of places you went to get your meals ______________________________________________

3. Have you been to any places in the last 2 weeks (14 days) to hang out or be with other people?

___________________________________________________________________________________

4. Did you receive any other services in the last 2 weeks (14 days) before your symptoms or your test was positive started? (Examples: Day shelters, shower/bathroom/lockers, case management, job placement/training)

Names of places______________________________________________________________________

5. Did you receive any medical services in the last 2 weeks (14 days) before your symptoms started or your test was positive? (Examples: mobile clinic, hospitals, ER, clinic)

____________________________________________________________________________________

6. Did you have a court date or stay in a correctional facility in the 2 weeks (14 days) before your symptoms started or your test was positive?

____________________________________________________________________________________

Laboratory testing

27. If yes, what type of specimen was collected?

Specimen Type	ORIGINAL Specimen ID
NP swab
OP swab
Nasal swab

This is the end of the case report form. Thank you very much for your time. If you have any questions please feel free to contact the CDC at 770-488-7100 or eocreport@cdc.gov

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Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011).