https://onlineforms.hi-precision.com.ph/

1

Philippine Integrated Disease Surveillance

and Response

Case Investigation Form Coronavirus Disease (COVID-19)

Version 7

General Instructions 1) The Case Investigation Form is meant to be administered as an Interview by a health care worker or any personnel of the Disease Reporting Unit. This is not a Self-Administered Questionnaire. 2) Please be advised that Disease Reporting Units are only allowed to obtain 1 copy of accomplished CIF from a patient. 3) Please fill out all blanks and put a check mark on the appropriate box. Never leave an item blank, just write N/A or not applicable. Items with * are required fields. 4) All dates must be in MM/DD/YYYY format.

Disease Reporting Unit* DRU Region and Province PhilHealth No.*

Name of Interviewer Contact Number of Interviewer Date of Interview (MM/DD/YYYY) *

Name of Informant (If patient unavailable) Relationship Contact Number of Informant

Type of Client COVID-19 Case (Suspect, Probable, or Confirmed) Close Contact

For RT-PCR Testing (Not a Case of Close Contact) Others, please specify

1. Testing Category / Subgroup (Check all that apply) Refer to Appendix 1 A B C D E F G H I J

Part 1. Patient Information 2. Patient Profile

Last Name* First Name (and Suffix)* Middle Name* Birthday (MM/DD/YYYY)* Age* Sex* Male Female

Civil Status Nationality Occupation 3. Current Address in the Philippines and Contact Information* (Give address of institution if you live in closed settings, see Part 2 #9)

House No./Lot/Bldg. Street/Purok/Sitio Barangay Municipality/City

Province Home Phone No. (& Area Code) Cellphone No. Email Address

4. Current Workplace Address and Contact Information Lot/Bldg. Street Barangay Municipality/City

Province Name of Workplace Phone No./Cellphone No. Email Address

5. Consultation and Admission Information Did you have previous COVID-19 related consultation? Yes, Date of First Consult (MM/DD/YYYY)* ____________________ No

Name of facility where first consult was done Was the case admitted in a health facility? Yes, Date of Admission (MM/DD/YYYY)* Indicate earliest date if

admitted in multiple health facilities ______________________ No

Name of Facility where patient was first admitted Region and Province of Facility

6. Disposition at Time of Report* (Provide name of hospital/isolation/quarantine facility) Admitted in hospital _________________________________ Date and Time admitted in hospital __________________________

Admitted in isolation/quarantine facility _________________ Date and Time isolated/quarantined in facility _________________

In home isolation/quarantine Date and Time isolated/quarantined at home _________________

Discharged to home If Discharged: Date of Discharge (MM/DD/YYYY)* _____________ Others: ________________________ 7. Health Status at Consult* Asymptomatic Mild Moderate Severe Critical

8. Case Classification* (Refer to Appendix 2) Suspect Probable Confirmed Non-COVID-19 Case

PART 2: Case Investigation Details 9. Special Population

Health Care Worker* Yes, Name & location of health facility ___________________________________ No Returning Overseas Filipino* Yes, Country of origin _________________________________________________ No

Foreign National Traveler* Yes, Country of origin _________________________________________________ No Locally Stranded Individual/APOR/Traveler*

Yes, City, Mun, & Prov of origin __________________________________________ No

Lives in Closed Settings* Yes, specify Type of Institution (e.g. prisons, residential facilities, retirement communities, care homes, camps etc.) _____________________________ and specify Name of Institution __________________________________________

No

10. Permanent Address and Contact Information (If different from current address)

House No./Lot/Bldg. Street /Purok/Sitio Barangay Municipality/City

Province Home Phone No. (& Area Code) Cellphone No. Email Address

11. Address Outside the Philippines and Contact Information (for Overseas Filipino Workers and Individuals with Residence outside PH)

House No./Lot/Bldg. Street Municipality/City Province

Country Place of Work Employer’s Name Employer’s/Office Contact No.

2

12. Clinical Information

Date of Onset of Illness (MM/DD/YYYY)* ____________________

Comorbidities (Check all that apply if present) Signs and Symptoms (Check all that apply if present)

Asymptomatic Fever _____ °C Cough General weakness Fatigue Headache Myalgia Sore throat Coryza

Dyspnea Anorexia Nausea Vomiting Diarrhea Altered Mental Status Anosmia (loss of smell) Ageusia (loss of taste) Others _____________

None Hypertension Diabetes Heart Disease Lung Disease

Gastrointestinal Genito-urinary Neurological Disease Cancer Others ___________________

Are you pregnant? Yes, LMP ________________ No

High-risk pregnancy? Yes No

Were you diagnosed to have Severe Acute Respiratory Illness? (Refer to Appendix 2) Yes No

Chest imaging findings suggestive of COVID-19

Imaging Done (Check all that apply) Results

Chest radiography Normal Pending

Hazy opacities, often rounded in morphology, with peripheral and lower lung distribution. Other findings, specify ___________________________________________

Chest CT Normal Pending

Multiple bilateral ground glass opacities, often rounded in morphology, with peripheral and lower lung distribution. Other findings, specify ___________________________________________

Lung ultrasound Normal Pending

Thickened pleural lines, B lines (multifocal, discrete, or confluent), consolidative patterns with or without air bronchograms. Other findings, specify ___________________________________________

None

13. Laboratory Information

Test Done* (Check all that apply)

Date Collected* Laboratory Results* Date Released

RT-PCR (OPS) Pending Negative Positive Equivocal

RT-PCR (NPS) Pending Negative Positive Equivocal

RT-PCR (OPS & NPS) Pending Negative Positive Equivocal

RT-PCR (specimen type _____________)

Pending Negative Positive Equivocal

Antigen Test Pending Negative Positive Equivocal

Antibody Test IgM (+) IgG (-) IgM (+) IgG (+)

IgM (-) IgG (+) IgM (-) IgG (-)

Others ____________ Specify Result:

Have you ever tested positive using RT-PCR before? Yes, Date of Specimen Collection (MM/DD/YYYY)* ______________ No

If Yes, Laboratory _______________________________________________ Number of previous RT-PCR swabs done ___________________________

14. Outcome/Condition at Time of Report*

Active (Currently admitted or in isolation/quarantine) Recovered, Date of Recovery (MM/DD/YYYY)* ______________________ Died, Date of Death (MM/DD/YYYY)* __________________________________________________________________________________________ Cause of Death* Immediate Cause _______________________________________________________________________________________________ Antecedent Cause _______________________________________________ Underlying Cause _______________________________________________

Part 3: Contact Tracing

15. Exposure History

History of exposure to known probable and/or confirmed COVID-19 case 14 days before the onset of signs and symptoms? OR If Asymptomatic, 14 days before swabbing or specimen collection?*

Yes, Date of LAST Contact (MM/DD/YYYY)* _______________________ No Unknown

Have you been in a place with a known COVID-19 community transmission 14 days before the onset of signs and symptoms? OR If Asymptomatic, 14 days before swabbing or specimen collection?*

Yes No Unknown exposure

If Yes, specify place (Check all that apply, provide details such as name of establishment, transport service, venue, location etc. and date of visit in MM/DD/YYYY).

Place Visited Details Date of Visit Place Visited Details Date of Visit

Health Facility Transportation

Closed Settings (e.g. Jail) Workplace

Market Local Travel

Home Social Gathering

International Travel Others

School

16. Travel History

History of travel/visit/work in other countries with a known COVID-19 transmission 14 days before the onset of signs and symptoms

Yes, Country of exit ____________________________ No

Airline/Sea vessel Flight/Vessel Number Date of Departure (MM/DD/YYYY) Date of Arrival in PH (MM/DD/YYYY)

History of travel/visit/work in other local place with a known COVID-19 transmission 14 days before the onset of signs and symptoms

Yes, Place of origin _____________________________ No

Airline/Sea vessel/Bus line/Train Flight/Vessel Number/ Bus No. Date of Departure (MM/DD/YYYY) Date of Arrival in the Current City/Mun (MM/DD/YYYY)

List the names of persons who were with you two days prior to onset of illness until this date and their contact numbers. *If asymptomatic, list the names of persons who were with you on the day you submitted specimen for testing until this date and their contact numbers. (Use additional space below if needed).

Name Contact No.

Disease Reporting UnitRow1: DRU Region and ProvinceRow1: PhilHealth NoRow1: Name of InterviewerRow1: Contact Number of InterviewerRow1: Date of Interview MMDDYYYY Row1: Name of Informant If patient unavailableRow1: RelationshipRow1: Contact Number of InformantRow1: Last Name: First Name and Suffix: Middle Name: Birthday MMDDYYYY: Age: Civil Status: Nationality: Occupation: House NoLotBldgRow1: StreetPurokSitioRow1: BarangayRow1: MunicipalityCityRow1: ProvinceRow1: Home Phone No Area CodeRow1: Cellphone NoRow1: Email AddressRow1: LotBldgRow1: StreetRow1: BarangayRow1_2: MunicipalityCityRow1_2: ProvinceRow1_2: Name of WorkplaceRow1: Phone NoCellphone NoRow1: Email AddressRow1_2: undefined_2: Yes Date of First Consult MMDDYYYY NoName of facility where first consult was done: admitted in multiple health facilities: Yes Date of Admission MMDDYYYY Indicate earliest date if admitted in multiple health facilities NoName of Facility where patient was first admitted: Yes Date of Admission MMDDYYYY Indicate earliest date if admitted in multiple health facilities NoRegion and Province of Facility: 6 Disposition at Time of Report Provide name of hospitalisolationquarantine facility: undefined_3: Date and Time admitted in hospital: undefined_4: Date and Time isolatedquarantined in facility: Date and Time isolatedquarantined at home: If Discharged Date of Discharge MMDDYYYY: undefined_5: undefined_6: 1: 2: undefined_7: care homes camps etc 1: care homes camps etc 2: House NoLotBldgRow1_2: Street PurokSitioRow1: BarangayRow1_3: MunicipalityCityRow1_3: ProvinceRow1_3: Home Phone No Area CodeRow1_2: Cellphone NoRow1_2: Email AddressRow1_3: House NoLotBldgRow1_3: StreetRow1_2: MunicipalityCityRow1_4: ProvinceRow1_4: CountryRow1: Place of WorkRow1: Employers NameRow1: EmployersOffice Contact NoRow1: Check Box1: OffCheck Box2: OffCheck Box3: OffCheck Box4: OffCheck Box5: OffCheck Box6: OffCheck Box7: OffCheck Box8: OffCheck Box9: OffCheck Box10: OffCheck Box11: OffCheck Box12: OffCheck Box13: OffCheck Box14: OffCheck Box15: OffCheck Box16: OffCheck Box17: OffCheck Box18: OffCheck Box19: OffCheck Box20: OffCheck Box21: OffCheck Box22: OffCheck Box23: OffCheck Box24: OffCheck Box25: OffCheck Box26: OffCheck Box27: OffCheck Box28: OffCheck Box29: OffCheck Box30: OffCheck Box31: OffCheck Box32: OffCheck Box33: OffCheck Box34: OffCheck Box35: OffCheck Box36: OffCheck Box37: OffCheck Box38: OffCheck Box39: OffCheck Box40: OffCheck Box41: OffCheck Box42: OffCheck Box43: OffDate of Onset of Illness: Asymptomatic_2: OffFever: OffCough: OffGeneral weakness: OffFatigue: OffHeadache: OffMyalgia: OffSore throat: OffCoryza: OffC_2: Dyspnea: OffAnorexia: OffNausea: OffVomiting: OffDiarrhea: OffAltered Mental Status: OffAnosmia loss of smell: OffAgeusia loss of taste: OffOthers_2: OffNone: OffHypertension: OffDiabetes: OffHeart Disease: OffLung Disease: OffGastrointestinal: OffGenitourinary: OffNeurological Disease: OffCancer: OffOthers_3: Offundefined_8: Yes LMP: OffNo_8: Offundefined_9: undefined_10: undefined_11: Offundefined_12: Offundefined_13: Offundefined_14: OffChest imaging findings suggestive of COVID19: undefined_15: OffNormal: OffPending: OffHazy opacities often rounded in morphology with peripheral and lower lung distribution: OffOther findings specify: Offundefined_16: undefined_17: OffNormal_2: OffPending_2: OffMultiple bilateral ground glass opacities often rounded in morphology with peripheral and: OffOther findings specify_2: Offundefined_18: undefined_19: OffNormal_3: OffPending_3: OffThickened pleural lines B lines multifocal discrete or confluent consolidative patterns: Offwith or without air bronchograms: Other findings specify_3: Offundefined_20: OffRTPCR OPS: OffDate CollectedRTPCR OPS: LaboratoryRTPCR OPS: Pending_4: OffNegative: OffPositive: OffEquivocal: OffDate ReleasedPending Negative Positive Equivocal: RTPCR NPS: OffDate CollectedRTPCR NPS: LaboratoryRTPCR NPS: Pending_5: OffNegative_2: OffPositive_2: OffEquivocal_2: OffDate ReleasedPending Negative Positive Equivocal_2: RTPCR OPS NPS: OffDate CollectedRTPCR OPS NPS: LaboratoryRTPCR OPS NPS: Pending_6: OffNegative_3: OffPositive_3: OffEquivocal_3: OffDate ReleasedPending Negative Positive Equivocal_3: RTPCR specimen type: OffPending_7: OffNegative_4: OffPositive_4: OffEquivocal_4: Offundefined_21: Date CollectedRTPCR specimen type: LaboratoryRTPCR specimen type: Date ReleasedPending Negative Positive Equivocal_4: Antigen Test: OffDate CollectedAntigen Test: LaboratoryAntigen Test: Pending_8: OffNegative_5: OffPositive_5: OffEquivocal_5: OffDate ReleasedPending Negative Positive Equivocal_5: Antibody Test: OffDate CollectedAntibody Test: LaboratoryAntibody Test: IgM IgG: OffIgM IgG_2: OffIgM IgG_3: OffIgM IgG_4: OffDate ReleasedRow6: Others_4: Offundefined_22: Date CollectedOthers: LaboratoryOthers: Date ReleasedSpecify Result: undefined_23: Yes Date of Specimen Collection MMDDYYYY: OffNo_9: OffIf Yes Laboratory: Number of previous RTPCR swabs done: Active Currently admitted or in isolationquarantine: OffDied Date of Death MMDDYYYY: OffRecovered Date of Recovery MMDDYYYY: undefined_24: Cause of Death Immediate Cause: Antecedent Cause: Underlying Cause: Yes Date of LAST Contact MMDDYYYY: OffNo_10: OffUnknown: Offundefined_25: undefined_26: Offundefined_27: Offundefined_28: OffDetailsHealth Facility: Date of VisitHealth Facility: DetailsTransportation: Date of VisitTransportation: DetailsClosed Settings eg Jail: Date of VisitClosed Settings eg Jail: DetailsWorkplace: Date of VisitWorkplace: DetailsMarket: Date of VisitMarket: DetailsLocal Travel: Date of VisitLocal Travel: DetailsHome: Date of VisitHome: DetailsSocial Gathering: Date of VisitSocial Gathering: DetailsInternational Travel: Date of VisitInternational Travel: DetailsOthers: DetailsSchool: Date of VisitSchool: Yes Country of exit: OffNo_11: Offundefined_29: AirlineSea vesselRow1: FlightVessel NumberRow1: Date of Departure MMDDYYYYRow1: Date of Arrival in PH MMDDYYYYRow1: Yes Place of origin: OffNo_12: Offundefined_30: AirlineSea vesselBus lineTrainRow1: FlightVessel Number Bus NoRow1: Date of Departure MMDDYYYYRow1_2: Date of Arrival in the Current CityMun MMDDYYYYRow1: NameList the names of persons who were with you two days prior to onset of illness until this date and their contact numbers If asymptomatic list the names of persons who were with you on the day you submitted specimen for testing until this date and their contact numbers Use additional space below if needed: Contact NoList the names of persons who were with you two days prior to onset of illness until this date and their contact numbers If asymptomatic list the names of persons who were with you on the day you submitted specimen for testing until this date and their contact numbers Use additional space below if needed: NameList the names of persons who were with you two days prior to onset of illness until this date and their contact numbers If asymptomatic list the names of persons who were with you on the day you submitted specimen for testing until this date and their contact numbers Use additional space below if needed_2: Contact NoList the names of persons who were with you two days prior to onset of illness until this date and their contact numbers If asymptomatic list the names of persons who were with you on the day you submitted specimen for testing until this date and their contact numbers Use additional space below if needed_2: NameList the names of persons who were with you two days prior to onset of illness until this date and their contact numbers If asymptomatic list the names of persons who were with you on the day you submitted specimen for testing until this date and their contact numbers Use additional space below if needed_3: Contact NoList the names of persons who were with you two days prior to onset of illness until this date and their contact numbers If asymptomatic list the names of persons who were with you on the day you submitted specimen for testing until this date and their contact numbers Use additional space below if needed_3: NameList the names of persons who were with you two days prior to onset of illness until this date and their contact numbers If asymptomatic list the names of persons who were with you on the day you submitted specimen for testing until this date and their contact numbers Use additional space below if needed_4: Contact NoList the names of persons who were with you two days prior to onset of illness until this date and their contact numbers If asymptomatic list the names of persons who were with you on the day you submitted specimen for testing until this date and their contact numbers Use additional space below if needed_4: Date ReleasedRow7: Specifyplacedetailsfacility: NameList the names of persons who were with you two days prior to onset of illness until this date and their contact numbers If asymptomatic list the names of persons who were with you on the day you submitted specimen for testing until this date and their contact numbers Use additional space below if needed_20: 25_Contact NoList the names of persons who were with you two days prior to onset of illness until this date and their contact numbers If asymptomatic list the names of persons who were with you on the day you submitted specimen for testing until this date and their contact numbers Use additional space below if needed: 21_NameList the names of persons who were with you two days prior to onset of illness until this date and their contact numbers If asymptomatic list the names of persons who were with you on the day you submitted specimen for testing until this date and their contact numbers Use additional space below if needed_2: 26_Contact NoList the names of persons who were with you two days prior to onset of illness until this date and their contact numbers If asymptomatic list the names of persons who were with you on the day you submitted specimen for testing until this date and their contact numbers Use additional space below if needed_2: 22_NameList the names of persons who were with you two days prior to onset of illness until this date and their contact numbers If asymptomatic list the names of persons who were with you on the day you submitted specimen for testing until this date and their contact numbers Use additional space below if needed_3: 27_Contact NoList the names of persons who were with you two days prior to onset of illness until this date and their contact numbers If asymptomatic list the names of persons who were with you on the day you submitted specimen for testing until this date and their contact numbers Use additional space below if needed_3: 24_NameList the names of persons who were with you two days prior to onset of illness until this date and their contact numbers If asymptomatic list the names of persons who were with you on the day you submitted specimen for testing until this date and their contact numbers Use additional space below if needed_4: 28_Contact NoList the names of persons who were with you two days prior to onset of illness until this date and their contact numbers If asymptomatic list the names of persons who were with you on the day you submitted specimen for testing until this date and their contact numbers Use additional space below if needed_4: DetailsOthersDate: Button1: