Public reporting burden of this collection of information is estimated to average 30 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).

CDC 2019-nCoV ID: Form Approved: OMB: 0920-1011 Exp. 4/23/2020

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

Patient first name _______________ Patient last name __________________ Date of birth (MM/DD/YYYY): ____/_____/_______

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

Human Infection with 2019 Novel Coronavirus

Person Under Investigation (PUI) and Case Report Form

Reporting jurisdiction: ______________ Case state/local ID: ______________

Reporting health department: ______________ CDC 2019-nCoV ID: ______________

Contact ID a: ______________ NNDSS loc. rec. ID/Case ID b: ______________ a. Only complete if case-patient is a known contact of prior source case-patient. Assign Contact ID using CDC 2019-nCoV ID and sequential contact ID, e.g., Confirmed case CA102034567 has contacts

CA102034567 -01 and CA102034567 -02. bFor NNDSS reporters, use GenV2 or NETSS patient identifier.

Interviewer information 

Name of interviewer: Last ______________________________ First ______________________________________ 

Affiliation/Organization: _______________________________ Telephone ________________ Email ______________________________

Basic information

What is the current status of this person? 

Patient under investigation (PUI)

Laboratory-confirmed case

Report date of PUI to CDC (MM/DD/YYYY):

____/_____/_______

Report date of case to CDC (MM/DD/YYYY):

____/_____/_______

County of residence: ___________________

State of residence: ___________________

Ethnicity:

Hispanic/Latino

Non-Hispanic/

Latino 

Not specified

Sex:

Male

Female

Unknown

Other

Date of first positive specimen 

collection (MM/DD/YYYY): 

____/_____/_______ 

Unknown N/A

Did the patient develop pneumonia? 

Yes Unknown

No

Did the patient have acute 

respiratory distress syndrome? 

Yes Unknown

No

Did the patient have another 

diagnosis/etiology for their illness? 

Yes Unknown

No

Did the patient have an abnormal 

chest X-ray? 

Yes Unknown

No

Was the patient hospitalized? 

Yes No Unknown

If yes, admission date 1 

___/___/___ (MM/DD/YYYY) 

If yes, discharge date 1 

__/___/____ (MM/DD/YYYY)

Was the patient admitted to an 

intensive care unit (ICU)?

Yes No Unknown

Did the patient receive mechanical 

ventilation (MV)/intubation?

Yes No Unknown

If yes, total days with MV (days) 

_______________

Did the patient receive ECMO?

Yes No Unknown

Did the patient die as a result of this

illness? 

Yes No Unknown 

Date of death (MM/DD/YYYY): 

____/_____/_______

Unknown date of death

Race (check all that apply):

American Indian/Alaska Native 

Native Hawaiian/Other Pacific Islander 

Unknown 

Asian 

Black 

White

Other, specify: _________________

Date of birth (MM/DD/YYYY): ____/_____/_______

Age: ____________

Age units(yr/mo/day): ________________

Symptoms present 

during course of illness:

Symptomatic

Asymptomatic

Unknown

If symptomatic, onset 

date (MM/DD/YYYY):

____/_____/_______ 

 Unknown 

If symptomatic, date of symptom resolution (MM/DD/YYYY): 

____/_____/_____ 

Still symptomatic Unknown symptom status

Symptoms resolved, unknown date

Is the patient a health care worker in the United States? Yes No Unknown

Does the patient have a history of being in a healthcare facility (as a patient, worker or visitor) in China? Yes No Unknown

In the 14 days prior to illness onset, did the patient have any of the following exposures (check all that apply):

Travel to Wuhan Community contact with another Exposure to a cluster of patients with severe acute lower 

Travel to Hubei lab-confirmed COVID-19 case-patient respiratory distress of unknown etiology

Travel to mainland China Any healthcare contact with another Other, specify:____________________

Travel to other non-US country lab-confirmed COVID-19 case-patient Unknown

specify:_____________________ Patient Visitor HCW

Household contact with another lab Animal exposure

confirmed COVID-19 case-patient

If the patient had contact with another COVID-19 case, was this person a U.S. case? Yes, nCoV ID of source case: _______________ No Unknown N/A

Under what process was the PUI or case first identified? (check all that apply): Clinical evaluation leading to PUI determination

Contact tracing of case patient Routine surveillance EpiX notification of travelers; if checked, DGMQID_______________

Unknown Other, specify:_________________

Symptoms, clinical course, past medical history and social history

Collected from (check all that apply): Patient interview Medical record review 
CDC 2019-nCoV ID: Form Approved: OMB: 0920-1011 Exp. 4/23/2020

Human Infection with 2019 Novel Coronavirus

Person Under Investigation (PUI) and Case Report Form

Public reporting burden of this collection of information is estimated to average 30 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).

2 

Pre-existing medical conditions? Yes No Unknown

Chronic Lung Disease (asthma/emphysema/COPD) Yes No Unknown

Diabetes Mellitus Yes No Unknown

Cardiovascular disease Yes No Unknown

Chronic Renal disease Yes No Unknown

Chronic Liver disease Yes No Unknown

Immunocompromised Condition Yes No Unknown

Neurologic/neurodevelopmental Yes No Unknown (If YES, specify) 

Other chronic diseases Yes No Unknown (If YES, specify) 

If female, currently pregnant Yes No Unknown

Current smoker Yes No Unknown

Former smoker Yes No Unknown

Respiratory Diagnostic Testing Specimens for COVID-19 Testing

Additional State/local Specimen IDs: ______________ ______________ ______________ ______________ ______________

During this illness, did the patient experience any of the following symptoms? Symptom Present?

Fever >100.4F (38C)c Yes No Unk

Subjective fever (felt feverish) Yes No Unk

Chills Yes No Unk

Muscle aches (myalgia) Yes No Unk

Runny nose (rhinorrhea) Yes No Unk

Sore throat Yes No Unk

Cough (new onset or worsening of chronic cough) Yes No Unk

Shortness of breath (dyspnea) Yes No Unk

Nausea or vomiting Yes No Unk

Headache Yes No Unk

Abdominal pain Yes No Unk

Diarrhea (≥3 loose/looser than normal stools/24hr period) Yes No Unk

Other, specify:_____________________________________________

Test Pos Neg Pend. Not done Specimen 

Type

Specimen 

ID

Date 

Collected

Sent to 

CDC

State Lab 

Tested

Influenza rapid Ag A B NP Swab

Influenza PCR A B OP Swab

RSV Sputum

H. metapneumovirus Other, 

Parainfluenza (1-4) Specify:

Adenovirus _________

Rhinovirus/enterovirus

Coronavirus (OC43, 229E, HKU1, NL63)

M. pneumoniae

C. pneumoniae

Other, Specify:__________________

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