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Case Investigation Form

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rmmmh.nursingoffice01
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30 views

Case Investigation Form

Uploaded by

rmmmh.nursingoffice01
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd
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1. The case investigation from (CIF) is meant to be administered as an interview by health care worker or any personnel of the DRU.

This is not a self administered questionnaire.


2. please be advised that DRU's are only allowed to obtain 1 copy of accomplished CIF from patient.
3. Please fill out all the blanks and put a check mark on the appropriate box. Never leave an item blank (write N/A). Items with * are required fields. All dates must be in MM/DD/YYYY format.
Disease Reporting Unit * DRU Region and Province Philhealth No.*

Name of Interviewer Contact Number of Interviewer Date of Interview (MM/DD/YYYY)*

Name of Informat (if applicable) Ralationship Contact number of Informat

o Not applicable (New Case) o Update case calssification o Update disposition


o Not applicable (Unknown) o Update vaccination o Update exposure/travel history
if existing case (check all that apply) o Update Symptoms o Update lab result o others, specify:
o Update health status/outcome o Update chest imaging findings

Type of Client* o COVID-19 Case (Suspect, Probable or Confirmed) o Close Contact o for RT-PCR Testing (Not a Case of Close Contact)
Testing Category/Subgroup* (Check all that apply, refer to Appendix 2) oA oB oC oD oE oF oG oH oI oJ

Part 1. Patient information


1.1 Patient Profile
Last Name * First Name (and Suffix)* Middle Name*
Birthday (MM/DD/YYYY)* Age* Sex* oMale oFemale
Civil Status Nationality*
Occupation Works in aclosed setting? oYes oNo oUnknown
1.2 Current Address in Philippines and Contact Information* (Provided address of Institution if patient lives in closed sttings, see 1.5)
House No./Lot/Bldg.* Street/Purok/Sitio* Barangay* Municipality/City*

Province*

1.3 Permanent Address and Contact Information (if different from current address)
House No./Lot/Bldg.*

Province*

1.4 Current Workplace Address and Contact Information


Lot/Bldg

Province

1.5 Special Population (indicate further details on exposure and travel history in Part 3)
Health Care Worker*
Returning Overseas

Foreign National Traveler*


Local Stranded Individual/ APOR?Local traveler*

Lives in Closed Settings*

Part 2. Case Investigation Details


2.1 Consultation information
Have previous COVID-19 related consultation?
name of Facility where first consult was done
2.2 Disposition at Time of Report* (Provide name of hospital/isolation/quarantine facility)
admitted in hospital
Admitted in isolation/quarantine facility
In home isolation/quarantine
discharged to home
2.3 Health Status at Consult* (Refer to Appendix 3)
2.4 Case Classification* (Reffer to Appendix 1)
2.5 Vaccination Information*
Date of Vaccination Name of Vaccine
format.

exposure/travel history

PCR Testing (Not a Case of Close Contact)

Home Phone No. (& Area Code) Cellphone No*

Street/Purok/Sitio* Barangay*

Home Phone No. (& Area Code) Cellphone No*

Street Barangay

Name of Workplace Phone No./Cellphone No.

Yes, name of Health Facility: and Location:


Yes, country of origin: _________________________ and Passport No: ____________
OFW: OFW Non-OFW
Yes, country of origin: _________________________ and Passport No: ____________
Yes, City, Municipality, and Province of origin
Locally stranded Individual Authorized Person Outside Residence/local Traveler
Yes, institution type: and name:
(e.g. Prisons, residential facilities, retirement communitities, care homes, camps, etc.)

Yes, Date of first Consult (MM/DD/YYYY)*

Date and time admitted in hospital


Date and isolated/quarantined in facility
Date and time isolated/quarantined at home
if dischared: Date of Discharge (MM/DD/YYYY)*
Asymtomatic Mild Moderate Severe Critical
Suspect Probable Confirmed Non-Covid 19 Case

Dose Number (e.g. 1st, 2nd)* Vaccination Center/Facility Region of Health Facility
Email Address

Municipality/City*

Email Address

Municipality

Email Address

No
No

No
No
ed Person Outside Residence/local Traveler
No

No

others

Non-Covid 19 Case

Region of Health Facility Adverse Even/s?


Yes No
Yes No

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