Get Covid-19 Case Report Form. Covid-19 Case Report Form

This guide provides comprehensive instructions on how to accurately complete the COVID-19 Case Report Form. By following these steps, you will ensure that all necessary information is submitted correctly for each laboratory confirmed COVID-19 patient.

Follow the steps to accurately complete the COVID-19 Case Report Form.

1. Press the ‘Get Form’ button to access the COVID-19 Case Report Form and open it in your preferred editor.
2. Fill in the reporter information section: Enter today’s date, provide the name of the hospital or clinic, clinician's name, and phone number. Additionally, include the disease reporter's name and their contact number.
3. In the COVID-19 testing information section, provide the lab name and the date of specimen collection. Indicate the type of specimen collected by selecting either NP, OP, or Other, and specify if applicable.
4. Complete the patient information section: Fill in the patient’s first and last name, phone number, full address, city, zip code, county, and state. Record the date of birth, age in years and months, and select the patient's sex.
5. Address the questions regarding the patient's work and living situations: Indicate if the patient works in a healthcare facility or congregate setting by checking yes or no. Provide the facility name and the employee occupation if applicable. Also, indicate whether the patient worked while ill and if they live in a congregate setting.
6. Provide clinical information: Enter the date of symptom onset. Specify if the patient is hospitalized and provide the admit date and hospital name. Indicate any additional clinical conditions such as ICU admission, intubation, whether the patient is deceased, chest X-ray or CT, and ECMO involvement.
7. Select any underlying conditions the patient may have, including options like immunocompromised, pregnancy, diabetes, chronic lung disease, and more. If other conditions exist, please specify.
8. Review all provided information for accuracy. Once confirmed, you can save changes, download, print, or share the completed form as needed.

Complete the COVID-19 Case Report Form online today to ensure timely reporting and support public health efforts.