COVID-19 Case Investigation Form

City of El Paso COVID-19 Case Investigation Form
COVID-19 Case Investigation
CASE INVESTIGATION FORM

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COVID-19 Case Investigation Form
Record ID
__________________________________
Case Creation Date

__________________________________
Case Number
__________________________________
Jurisdiction ELP
FT BLISS
NM
MEXICO
OTHER
BINATIONAL
Notification date
__________________________________
(yyyy-mm-dd)
Data entry person
__________________________________
DEMOGRAPHICS
Demographics:
Patient's name (Last name, First name)
__________________________________
Birth date:
__________________________________
(yyyy-mm-dd)
Calculated Age
__________________________________
Age
__________________________________
Gender Male
Female
Other
Other:
__________________________________
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05-20-2020 12:38 Powered by REDCap
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Race White
Black
Asian
Pacific Islander
Native American/ Alaskan
Unknown
Other
Other:
__________________________________
Hispanic Yes
No
Address:
__________________________________
(street)
City:
__________________________________
(city)
Zip Code:
__________________________________
State:
__________________________________
Home phone:
__________________________________
(915/555-1212)
Cell phone:
__________________________________
(915/555-1212)
Investigator's name:
__________________________________
Investigation start date:
__________________________________
(yyyy-mm-dd)
2
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Reported by (Lab) DPH Lab

Quest
Lab Corp
CPL
Other
WBAMC
STATE
Name of Laboratory (Other)

__________________________________
Reported by (Hospital, HCP) THOP- East

THOP- Transmountain
THOP- Memorial
THOP- Sierra
THOP- Horizon
EPCH
UMC
Las Palmas MC
Del Sol MC
WBAMC
Other
Name of reporting facility

__________________________________
COVID-19 FACTORS
Covid factors
Underlying medical conditions?
No
Yes
Unknown
Underlying condition:
__________________________________
Disabilities
__________________________________
Does the patient have medical insurance? Yes

No
Type of medical insurance Private

Medicaid
Medicare
Other
Other insurance
__________________________________
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Travel (Including Juarez and New Mexico):
No
Yes
Unknown
Travel history:
__________________________________
Is the case a Health care worker? Yes

No
Unemployed:
No
Yes
Unknown
Name of employer:
__________________________________
Employer's address
__________________________________
Occupation:
__________________________________
Last day at work
__________________________________
(yyyy-mm-dd)
Student?
No
Yes
Unknown
Name of school:
__________________________________
Is the patient in a shelter? Yes

No
Name of the shelter

__________________________________
Is the patient in a correctional/detention facility? Yes

No
4
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Please indicate whether staff or resident Staff

Resident
Name of the facility

__________________________________
Resident or staff at a nursing home or assisted Yes

living facility: No
Please indicate whether staff or resident Staff

Resident
Name of nursing home or assisted living facility

__________________________________
Is the case part of a home health care agency? Yes

No
Please indicate whether staff or patient Staff

Patient
Name of Home Health Care Agency

__________________________________
Is the case a patient/staff at a behavioral or mental Yes

health facility? No
Please indicate whether staff or patient Staff

Patient
Name of the facility

__________________________________
Associated to a confirmed COVID-19 case:
No
Yes
Unknown
Associated case name (s):
__________________________________
Have you attended any parties or reunions 14 days prior to onset of symptoms:
No
Yes
Unknown
5
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HOSPITALIZATION
Hospitalization:
Hospital admission?
No
Yes
Unknown
Hospital name
__________________________________
Admission date:
__________________________________
(yyyy-mm-dd)
Onset of symptoms date:
__________________________________
(yyyy-mm-dd)
Symptoms
(symptom|symptom|symptom|)
Symptomatic
Asymptomatic
Symptoms
__________________________________
ICU Admission?
No
Yes
Unknown
ICU admission date:
__________________________________
(yyyy-mm-dd)
Discharged from ICU? Yes

No
Discharge ICU date:
__________________________________
(yyyy-mm-dd)
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Ventilator:
No
Yes
Unknown
Start of ventilator date:
__________________________________
(yyyy-mm-dd)
Out of Ventilator? Yes

No
Out of ventilator date:
__________________________________
(yyyy-mm-dd)
Discharged from hospital: Yes

No
Unknown
Discharge date:
__________________________________
(yyyy-mm-dd)
Ambulance Transport?
No
Yes
Unknown
Ambulance transport date:
__________________________________
(yyyy-mm-dd)
Expired?
No
Yes
Unknown
Date of death:
__________________________________
(yyyy-mm-dd)
Cause of death: COVID-19 related

non- COVID-19 related
Under investigation
7
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Notes:
__________________________________
Self isolation period.

SECTION 2 – Case Contact Investigation
Section 2 Case Contact Investigation

From 48 hours before onset of symptoms identify all the exposures that the patient had
(home, work, friends, etc.).
From 48 hours before onset of symptoms identify all the exposures that the patient had
Classify
(home, work,them according
friends, to DSHS exposure risk categories.
etc.).
Classify them according to DSHS exposure risk categories.
HIGH RISK CONTACTS

High risk contacts:
Contacts entry date
__________________________________
(yyyy-mm-dd)
High risk name 1:
__________________________________
Date of Birth:
__________________________________
(yyyy-mm-dd)
Phone #, Address
__________________________________
Date last contact with confirmed case:
__________________________________
(yyyy-mm-dd)
High risk name 2:
__________________________________
Date of Birth:
__________________________________
(yyyy-mm-dd)
Phone #, Address
__________________________________
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__________________________________
(yyyy-mm-dd)
High risk name 3:
__________________________________
Date of Birth:
__________________________________
(yyyy-mm-dd)
Phone #, Address
__________________________________
__________________________________
(yyyy-mm-dd)
High risk name 4:
__________________________________
Date of Birth:
__________________________________
(yyyy-mm-dd)
Phone #, Address
__________________________________
__________________________________
(yyyy-mm-dd)
High risk name 5:
__________________________________
Date of Birth:
__________________________________
(yyyy-mm-dd)
9
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Phone #, Address
__________________________________
__________________________________
(yyyy-mm-dd)
High risk name 6:
__________________________________
Date of Birth:
__________________________________
(yyyy-mm-dd)
Phone #, Address
__________________________________
__________________________________
(yyyy-mm-dd)
High risk name 7:
__________________________________
Date of Birth:
__________________________________
(yyyy-mm-dd)
Phone #, Address
__________________________________
__________________________________
(yyyy-mm-dd)
High risk name 8:
__________________________________
10
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Date of Birth:
__________________________________
(yyyy-mm-dd)
Phone #, Address
__________________________________
__________________________________
(yyyy-mm-dd)
High risk name 9:
__________________________________
Date of Birth:
__________________________________
(yyyy-mm-dd)
Phone #, Address
__________________________________
__________________________________
(yyyy-mm-dd)
High risk name 10:
__________________________________
Date of Birth:
__________________________________
(yyyy-mm-dd)
Phone #, Address
__________________________________
__________________________________
(yyyy-mm-dd)
11
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MEDIUM RISK CONTACTS

Medium risk contacts:
Medium risk name 1:
__________________________________
Date of Birth:
__________________________________
(yyyy-mm-dd)
Phone #, Address
__________________________________
__________________________________
(yyyy-mm-dd)
Medium risk name 2:
__________________________________
Date of Birth:
__________________________________
(yyyy-mm-dd)
Phone #, Address
__________________________________
__________________________________
(yyyy-mm-dd)
Medium risk name 3:
__________________________________
Date of Birth:
__________________________________
(yyyy-mm-dd)
Phone #, Address
__________________________________
12
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__________________________________
(yyyy-mm-dd)
Medium risk name 4:
__________________________________
Date of Birth:
__________________________________
(yyyy-mm-dd)
Phone #, Address
__________________________________
__________________________________
(yyyy-mm-dd)
Medium risk name 5:
__________________________________
Date of Birth:
__________________________________
(yyyy-mm-dd)
Phone #, Address
__________________________________
__________________________________
(yyyy-mm-dd)
Medium risk name 6:
__________________________________
Date of Birth:
__________________________________
(yyyy-mm-dd)
13
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Phone #, Address
__________________________________
__________________________________
(yyyy-mm-dd)
Medium risk name 7:
__________________________________
Date of Birth:
__________________________________
(yyyy-mm-dd)
Phone #, Address
__________________________________
__________________________________
(yyyy-mm-dd)
Medium risk name 8:
__________________________________
Date of Birth:
__________________________________
(yyyy-mm-dd)
Phone #, Address
__________________________________
__________________________________
(yyyy-mm-dd)
Medium risk name 9:
__________________________________
14
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Date of Birth:
Date of Birth:
__________________________________
__________________________________
(yyyy-mm-dd)
(yyyy-mm-dd)
Phone #, Address
Phone #, Address
__________________________________
__________________________________

__________________________________
__________________________________
(yyyy-mm-dd)
(yyyy-mm-dd)
Medium risk name 10:

Medium risk name 10:
__________________________________
__________________________________
Date of Birth:
Date of Birth:
__________________________________
__________________________________
(yyyy-mm-dd)
(yyyy-mm-dd)
Phone #, Address
Phone #, Address
__________________________________
__________________________________

__________________________________
__________________________________
(yyyy-mm-dd)
(yyyy-mm-dd)
Low risk RISK

LOW contacts:
CONTACTS
Low risk contacts:
Low risk name 1:
Low risk name 1:
__________________________________
__________________________________
Date of Birth:
Date of Birth:
__________________________________
__________________________________
(yyyy-mm-dd)
(yyyy-mm-dd)
Phone #, Address
Phone #, Address
__________________________________
__________________________________

__________________________________
__________________________________
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Low risk name 2:
__________________________________
Date of Birth:
__________________________________
(yyyy-mm-dd)
Phone #, Address
__________________________________
__________________________________
Low risk name 3:
__________________________________
Date of Birth:
__________________________________
(yyyy-mm-dd)
Phone #, Address
__________________________________
__________________________________
Low risk name 4:
__________________________________
Date of Birth:
__________________________________
(yyyy-mm-dd)
Phone #, Address
__________________________________
__________________________________
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Low risk name 5:
__________________________________
Date of Birth:
__________________________________
(yyyy-mm-dd)
Phone #, Address
__________________________________
__________________________________
Low risk name 6:
__________________________________
Date of Birth:
__________________________________
(yyyy-mm-dd)
Phone #, Address
__________________________________
__________________________________
Low risk name 7:
__________________________________
Date of Birth:
__________________________________
(yyyy-mm-dd)
Phone #, Address
__________________________________
__________________________________
17
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Low risk name 8:
__________________________________
Date of Birth:
__________________________________
(yyyy-mm-dd)
Phone #, Address
__________________________________
__________________________________
Low risk name 9:
__________________________________
Date of Birth:
__________________________________
(yyyy-mm-dd)
Phone #, Address
__________________________________
__________________________________
Low risk name 10:
__________________________________
Date of Birth:
__________________________________
(yyyy-mm-dd)
Phone #, Address
__________________________________
__________________________________
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COVID-19 confirmed case needs to remain in self-isolation for 14 days after onset of symptoms. You should follow-up
with this patient. ONSET OF SYMPTOMS DATE [dt_onset] + 14 DAYS =
__________________________________
(yyyy-mm-dd)
SECTION 3 – To be completed 14 days after onset of symptoms.

Section 3. To be completed 14 days after onset of symptoms
Hospital re-admission:
No
Yes
Unknown
Re-admission date:
__________________________________
(yyyy-mm-dd)
ICU admission:
No
Yes
Unknown
ICU Re-admission date:
__________________________________
(yyyy-mm-dd)
ICU Re-admission discharge date:
__________________________________
(yyyy-mm-dd)
Ventilator:
No
Yes
Unknown
Re-admission start of ventilator date:
__________________________________
(yyyy-mm-dd)
Re-admission end of ventilator date:
__________________________________
(yyyy-mm-dd)
Hospital Re-admission Discharge Date:
__________________________________
(yyyy-mm-dd)
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Ambulance Transport?
No
Yes
Unknown
Ambulance transport date:
__________________________________
(yyyy-mm-dd)
Out of isolation?
No
Yes
Unknown
Date out of isolation:
__________________________________
(yyyy-mm-dd)
Education level Elementary

Middle school
High school diploma
Associate's degree
Bachelor's degree
Master's degree
Doctoral degree
No education
Refused to answer
Household income (per year) Less than $20,000

Between $20,000-$30,000
Between $30,000-$40,000
Between $40,000-$50,000
Between $50,000-$60,000
Between $60,000-$70,000
Between $70,000-$80,000
Between $80,000-$90,000
Between $90,000-$100,000
Between $100,000-$125,000
Between $125,000-$150,000
Over $150,000
Refused to answer
Did you follow home-quarantine recommendation? Yes

No
Did you use a face-mask? Yes

No
Do you follow regular hand-washing practices? Yes

No
Recovered? Yes
No
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Media Reporting Date

__________________________________
Patient email address

__________________________________
Follow-up calls Yes

No
Follow-up call #1 Date

__________________________________
Follow-up call#1 Notes

__________________________________

__________________________________

__________________________________

__________________________________

__________________________________

__________________________________

__________________________________

__________________________________

__________________________________
Do you have a second job? Yes

No
Employer's name #2
__________________________________
Employer's address #2
__________________________________
Have you been at restaurants 14 days prior onset of Yes

symptoms or collection date? No
Have you been visiting stores 14 days prior onset of Yes

symptoms or collection date? No
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Have you been attending athletic clubs (gym) 14 days Yes

prior onset of symptoms or collection date? No
Have you attended any large gatherings such as Yes

concerts, events, etc... 14 days prior onset of No
symptoms or collection date?
22

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City of El Paso COVID-19 Case Investigation Form

COVID-19 Case Investigation

CASE INVESTIGATION FORM

Case Creation Date

Data entry person

Investigation start date:

Reported by (Lab) DPH Lab

Name of Laboratory (Other)

Reported by (Hospital, HCP) THOP- East

Name of reporting facility

Does the patient have medical insurance? Yes

Type of medical insurance Private

Travel (Including Juarez and New Mexico):

Is the case a Health care worker? Yes

Last day at work

Is the patient in a shelter? Yes

Name of the shelter

Is the patient in a correctional/detention facility? Yes

Please indicate whether staff or resident Staff

Name of the facility

Resident or staff at a nursing home or assisted Yes

Please indicate whether staff or resident Staff

Name of nursing home or assisted living facility

Is the case part of a home health care agency? Yes

Please indicate whether staff or patient Staff

Name of Home Health Care Agency

Is the case a patient/staff at a behavioral or mental Yes

Please indicate whether staff or patient Staff

Name of the facility

Associated to a confirmed COVID-19 case:

Associated case name (s):

Onset of symptoms date:

ICU admission date:

Discharged from ICU? Yes

Discharge ICU date:

Start of ventilator date:

Out of Ventilator? Yes

Out of ventilator date:

Discharged from hospital: Yes

Ambulance transport date:

Cause of death: COVID-19 related

Self isolation period.

Section 2 Case Contact Investigation

Classify them according to DSHS exposure risk categories.

HIGH RISK CONTACTS

High risk name 1:

Date last contact with confirmed case:

High risk name 2:

Date last contact with confirmed case:

High risk name 3:

Date last contact with confirmed case:

High risk name 4:

Date last contact with confirmed case:

High risk name 5:

Date last contact with confirmed case:

High risk name 6:

Date last contact with confirmed case:

High risk name 7:

Date last contact with confirmed case: