1. Case State / Local ID
2.Medical Record Number (MRN):
3.Reporting Health Department Jurisdiction:* must provide value
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming District of Columbia
4.Name of Individual Entering Data:* must provide value
Name of the LTCF* must provide value
5.Date of Data Entry* must provide value
Today M-D-Y
Last Name* must provide value
First Name* must provide value
Date of birth* must provide value
Today M-D-Y
6.Age* must provide value
7.Sex * must provide value
Male Female Other Unknown
8.Ethnicity Hispanic Non-Hispanic Unknown
9.Race African American/Black Asian American Indian/Alaskan Native Native Hawaiian/Other Pacific Islander White Unknown Other
If other, please list:
10.Nursing Home ID* must provide value
11.Nursing Home County
12.Is person a resident or staff at the facility?* must provide value
Nursing Home Resident Healthcare Provider or staff Unknown
12a. If resident, length of stay in nursing home in days
12b. If healthcare personnel or staff, what is the job type: Nurse Doctor Certified Nurse Assistant Administrator Physical / Occupational Therapist Respiratory Therapist Unit Manager Volunteer Other Unknown
If other please list:
13.Does the patient have any pre-existing medical conditions? * must provide value
Yes No Unknown
Asthma/Reactive Airways Disease Yes No Unknown
Chronic Obstructive Pulmonary Disease (COPD) Yes No Unknown
Other chronic lung disease Yes No Unknown
If other, please explain:
Active Tuberculosis Yes No Unknown
Diabetes Mellitus (Type I or Type II) Yes No Unknown
Other endocrine disorder Yes No Unknown
If yes, what other endocrine disorder?
Hypertension Yes No Unknown
Coronary Artery Disease Yes No Unknown
Heart Failure Yes No Unknown
Cerebrovascular Accident/Stroke Yes No Unknown
Congenital Heart Disease Yes No Unknown
Other cardiovascular disease Yes No Unknown
If yes, what other cardiovascular disease?
Chronic kidney disease/insufficiency Yes No Unknown
End-stage renal disease Yes No Unknown
Dialysis Yes No Unknown
Hemodialysis Yes No Unknown
Peritoneal Dialysis Yes No Unknown
Other Kidney Disease Yes No Unknown
If yes, what other kidney disorder?
Alcoholic Hepatitis Yes No Unknown
Cirrhosis / End-Stage Liver Disease Yes No Unknown
Hepatitis B, chronic Yes No Unknown
Hepatitis C, chronic Yes No Unknown
Non-alcoholic Fatty Liver Disease (NAFLD) / Non-Alcoholic Steatohepatitis (NASH) Yes No Unknown
Other liver disease: Yes No Unknown
If yes, what other liver disorder?
HIV Yes No Unknown
AIDS or CD4 < 200 Yes No Unknown
Solid Organ Transplant Recipient Yes No Unknown
Stem Cell Transplant Recipient Yes No Unknown
Lymphoma or Leukemia: current/in treatment or diagnosed within 12 months Yes No Unknown
Solid organ cancer: current/in treatment or diagnosed within 12 months Yes No Unknown
Other immunocompromising condition Yes No Unknown
If yes, what other immunocompromising condition?
Please list any immunosuppressive treatment or therapy
Neurological / Neurodevelopmental disorder Yes No Unknown
If yes, what neurodevelopmental disorder?
Rheumatologic disorder Yes No Unknown
If yes, what rheumatologic disorder?
Psychiatric Disorder? Yes No Unknown
If yes, what psychiatric disorder?
Please list any other medical conditions:
Is this questionnaire being filled out to investigate a potential reinfection, potential vaccine failure, or both? Reinfection
Vaccine failure
Check both if appropriate
What date did the patient received the FIRST dose of the vaccine? * must provide value
Today M-D-Y
First dose vaccine name* must provide value
Pfizer
Moderna
Other
If selected "other" vaccine, please write the name:
Did the patient receive a second dose of vaccine? Yes
No
Unknown
What date did the patient received the SECOND dose of the vaccine? Today M-D-Y
Second dose vaccine name* must provide value
Pfizer
Moderna
Other
If selected "other" vaccine, please write the name:
14. Date of initial positive test result: Today M-D-Y
15. Type of initial positive test* must provide value
RT-PCR Antigen IgM-Antibody Unknown
15a. If known, please describe initial test platform
15b. If known, list Cycle Threshold (Ct) value
16.Was the individual symptomatic within two weeks, before or after, the initial positive test?* must provide value
Yes No Unknown
16a. If yes, do you know when symptoms began? Today M-D-Y
16b. If yes, do you know when symptoms ended? Today M-D-Y
17.Were they hospitalized during initial episode? Yes No Unknown
17a.If yes, how long were they hospitalized in days?
17b.If yes, did they require supplemental oxygen? Yes No Unknown
17c. If yes, were they admitted to the intensive care unit (ICU)? Yes No Unknown
17d. If yes, were they intubated? Yes No Unknown
18.What was the date of repeat or most recent positive test? Today M-D-Y
19.Type of repeat positive test: * must provide value
RT-PCR Antigen IgM-Antibody Unknown
19a.If known, describe the initial lab test (assay/platform) used
19b. What was the Cycle Threshold value, if available?
20.Why was the patient tested? Select all that apply: Asymptomatic screening at non-nursing home (e.g., hospital discharge, pre-op)
Asymptomatic screening at nursing home for baseline entry
Asymptomatic screening because of known exposure to patient with COVID-19
Symptomatic testing at nursing home
In response to outbreak testing
Unknown
20i. If response to outbreak, date of outbreak (first HCP or nursing home resident with a positive test): Today M-D-Y
20ii.Was this the index patient for the outbreak? Yes No Unknown
20iii.If no, how many other tests were positive before this patients' test?
21.Was the individual symptomatic within two weeks, before or after this test? * must provide value
Yes No Unknown
21a.When did symptoms begin? Today M-D-Y
21b.When did symptoms end? Today M-D-Y
22.If nursing home resident, was he or she isolated in response to presumed reinfection? Yes No Unknown N/A
23.Did he or she have any known exposures 14 days prior to the test (defined as being within 6 feet for a total of 15 minutes or longer of a known positive COVID-19 patient at least 2 days prior to symptom onset)? Yes No Unknown
23a.If yes, what was the exposure? (Select all that apply) Contacts who were known positive with SARS-CoV-2
Contacts with symptoms but unknown SARS-CoV-2 status
Healthcare personnel only - community gatherings
NH resident only - contacts outside facility (e.g., outside doctor appointments, or dialysis treatments)
Other
Unknown
If other, please describe exposure:
24.Is the INITIAL positive specimen available for culture and/or sequencing, either locally or at CDC? Yes No Unknown
24a. If yes, where? CDC Private/Contracted lab State Public Health Lab Unknown Other
24b. If other location, where?
24c. If CDC, what is the GFAT number?
25.If known, what is the INITIAL positive test culture result: Positive Growth No Growth Specimen was not cultured Unknown
26.If known, what is the INITIAL positive test sgmRNA sequencing result: Positive Negative Not Sequenced Unknown
27.Is the REPEAT positive test after 90 days available for culture and/or sequencing, either locally or at CDC? Yes No Unknown
27a. If yes, where? CDC Private/Contracted lab State public health lab Other Unknown
27b. If other, please list:
27c.If CDC, what are the GFAT Identification Numbers:
28.If known, what is the REPEAT positive test culture result: Positive Growth No Growth Specimen was not cultured Unknown
29.If known, what is the REPEAT positive RNA sequencing result Positive Negative Not Sequenced Unknown
30.For specimens that result in outbreak testing, are any specimens from additional residents or HCP that are available for testing? Yes No Unknown
31.Did the individual also receive any additional SARS-CoV-2 testing (other than their initial, or REPEAT/MOST RECENT test)?* must provide value
Yes No Unknown
What was the date of additional test 1? Today M-D-Y
What was the date of additional test 2? Today M-D-Y
What was the date of additional test 3? Today M-D-Y
What was the date of additional test 4? Today M-D-Y
What was the date of additional test 5? Today M-D-Y
What was the date of additional test 6? Today M-D-Y
What was the date of additional test 7? Today M-D-Y
What was the date of additional test 8? Today M-D-Y
What was the date of additional test 9? Today M-D-Y
What was the date of additional test 10? Today M-D-Y
What was the result of additional test 1? Positive Negative Unknown
What was the result of additional test 2? Positive Negative Unknown
What was the result of additional test 3? Positive Negative Unknown
What was the result of additional test 4? Positive Negative Unknown
What was the result of additional test 5? Positive Negative Unknown
What was the result of additional test 6? Positive Negative Unknown
What was the result of additional test 7? Positive Negative Unknown
What was the result of additional test 8? Positive Negative Unknown
What was the result of additional test 9? Positive Negative Unknown
What was the result of additional test 10? Positive Negative Unknown
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