Get As Soon As Possible, Notify And Send Completed Form To: 1) Your Local/state Health Department, And

Filling out the Middle East Respiratory Syndrome (MERS) Patient Under Investigation (PUI) Short Form is an important step in notifying health authorities about potential cases. This guide provides clear, step-by-step instructions to assist you in accurately completing and submitting the form.

Follow the steps to successfully complete the form online.

1. Click the ‘Get Form’ button to obtain the form and open it in the document editor.
2. Fill in today’s date and provide the state ID, state, and county information in the designated fields.
3. In the interviewer's section, enter the name, phone number, and email address of the individual completing the form.
4. Indicate the sex of the person being assessed by marking the appropriate box. Also, provide the age in years and months.
5. Specify the residency status by indicating whether the individual is a US resident or a non-US resident, and include the respective country name if applicable.
6. Input the date of symptom onset and mark all symptoms that apply from the list provided.
7. Complete the section regarding the patient’s exposure in the 14 days prior to symptom onset. Mark all relevant checkboxes and provide additional country information as needed.
8. Indicate if the patient is part of a severe respiratory illness cluster or a health care worker, and if they had worked in/around a country in the Arabian Peninsula.
9. Document any comorbid conditions by marking pertinent health issues, and indicate if the patient was hospitalized, admitted to the ICU, intubated, or deceased, along with respective dates.
10. Complete the laboratory testing section, marking all tests conducted, and their results accordingly.
11. Review the completed form for accuracy. Save changes, download, print, or share the form as necessary.

Complete your documents online to ensure timely reporting and compliance.