"2019 Novel Coronavirus (Covid-19) Case Report Form" - Connecticut

2019 Novel Coronavirus (Covid-19) Case Report Form is a legal document that was released by the Connecticut State Department of Public Health - a government authority operating within Connecticut.

Form Details:

  • Released on March 26, 2020;
  • The latest edition currently provided by the Connecticut State Department of Public Health;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Public Health.

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Download "2019 Novel Coronavirus (Covid-19) Case Report Form" - Connecticut

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Connecticut Department of Public Health
2019 Novel Coronavirus (COVID-19) Case Report Form
Please complete the following information for all patients with a laboratory-confirmed diagnosis of
COVID-19. Fax completed forms to DPH Epidemiology & Emerging Infections Program 860-629-6962.
PATIENT INFORMATION
All dates in mm/dd/yyyy format.
Name Last __________________________ First __________________________ Middle ______________
Street Address_____________________________________________________________________________
City___________________________________ County______________ State__________ Zip ___________
Phone: ____________________________
Date of Birth ______________
Race
Asian
American Indian/Alaska Native
Black/African American
Native Hawaiian/Other Pacific Islander
White
Unknown
Other, specify: __________
Ethnicity: Hispanic/Latino
Yes
No
Unknown
Gender
Female
Male
Other
Unknown
If female, pregnant?
Yes
No
Unknown
Did patient reside or spend time in a congregate setting?
Yes
No
Reside
Attend
Work in
Volunteer
Long term care facility/assisted living
Homeless shelter
Jail/prison
Other
If yes, name of facility: __________________
Town: ________________
Is the patient a healthcare worker?
Yes
No
If yes, name of facility: __________________
Town: ________________
Were there any symptoms associated with this illness/event?
Yes
No
Unknown
If symptomatic, date of onset ________________
Symptoms
Cough
Fever
Shortness of breath
Fatigue
Headache
Did the patient develop pneumonia?
Yes
No
Unknown
If yes, abnormal chest CT/x-ray:
Was the patient hospitalized?
Yes
No
Unknown
If yes, Hospital Name ________________________________________ MR# _________________
Admission date:______________
Discharge date: ______________
Was patient treated in the ICU?
Yes
No
Unknown
Did patient die?
No
Yes (date of death: ______________)
PROVIDER/REPORTER & FACILITY INFORMATION
Healthcare Provider: Last ____________________________________ First ___________________________
Person Completing Report: Last ______________________________ First __________________________
Facility Name: ______________________________________________________________________________
Facility Address: ____________________________________________________________________________
Phone Number: _____________________________
Fax Number: ____________________________
Email Address: ______________________________
DPH USE
Case ID: _________________________
Report Date: _________________________
mm/dd/yyyy
Rev. 3/26/2020
Connecticut Department of Public Health
2019 Novel Coronavirus (COVID-19) Case Report Form
Please complete the following information for all patients with a laboratory-confirmed diagnosis of
COVID-19. Fax completed forms to DPH Epidemiology & Emerging Infections Program 860-629-6962.
PATIENT INFORMATION
All dates in mm/dd/yyyy format.
Name Last __________________________ First __________________________ Middle ______________
Street Address_____________________________________________________________________________
City___________________________________ County______________ State__________ Zip ___________
Phone: ____________________________
Date of Birth ______________
Race
Asian
American Indian/Alaska Native
Black/African American
Native Hawaiian/Other Pacific Islander
White
Unknown
Other, specify: __________
Ethnicity: Hispanic/Latino
Yes
No
Unknown
Gender
Female
Male
Other
Unknown
If female, pregnant?
Yes
No
Unknown
Did patient reside or spend time in a congregate setting?
Yes
No
Reside
Attend
Work in
Volunteer
Long term care facility/assisted living
Homeless shelter
Jail/prison
Other
If yes, name of facility: __________________
Town: ________________
Is the patient a healthcare worker?
Yes
No
If yes, name of facility: __________________
Town: ________________
Were there any symptoms associated with this illness/event?
Yes
No
Unknown
If symptomatic, date of onset ________________
Symptoms
Cough
Fever
Shortness of breath
Fatigue
Headache
Did the patient develop pneumonia?
Yes
No
Unknown
If yes, abnormal chest CT/x-ray:
Was the patient hospitalized?
Yes
No
Unknown
If yes, Hospital Name ________________________________________ MR# _________________
Admission date:______________
Discharge date: ______________
Was patient treated in the ICU?
Yes
No
Unknown
Did patient die?
No
Yes (date of death: ______________)
PROVIDER/REPORTER & FACILITY INFORMATION
Healthcare Provider: Last ____________________________________ First ___________________________
Person Completing Report: Last ______________________________ First __________________________
Facility Name: ______________________________________________________________________________
Facility Address: ____________________________________________________________________________
Phone Number: _____________________________
Fax Number: ____________________________
Email Address: ______________________________
DPH USE
Case ID: _________________________
Report Date: _________________________
mm/dd/yyyy
Rev. 3/26/2020