CENTRAL CASE NUMBER

Form A To be filled at NCDC

NATIONAL CENTRE FOR DISEASE CONTROL
(To be filled COVID-19 Acute Respiratory Disease)

A PATIENT INFORMATION
1. Name of patient: Age/Gender Date of interview

2. Name of Health Facility where isolated: District (Isolation facility): State (Isolation facility):

3. Name of interviewer Address of interviewer: Contact Number of interviewer:

4. Case Classification: Confirmed Suspect
5. Current Status of case: Stable □ Admitted in ICU □ Deceased □
B SOCIODEMOGRAPHC PROFILE
Nationality: Indian Non-Indian (Name of country) …………………………………..
Postal Address District Phone email id
number
C CLINICAL INFORMATION
1 Patient clinical course
1.1 Date of Onset of symptoms
1.2 Details of contact with heath facility
(name of health facility: ) (date of contact with health facility: )
(name of health facility: ) (date of contact with health facility: )
(name of health facility: ) (date of contact with health facility: )
(name of health facility: ) (date of contact with health facility: )
1.3 Date of admission to isolation facility:
1.4 Outcome (circle): Under treatment/ Discharged/ LAMA/ Died 1.5Date of outcome(if applicable)
1.5 Cause of death (As mentioned on death certificate):
2 Patient Symptoms at admission (tick all reported)
a) Fever/chills b) Sore throat c) Nausea/Vomiting
d) General weakness e) Breathlessness f) Headache
g) Cough h) Diarrhea i) Irritability/confusion
j) Runny nose k) Pain(circle)muscular, chest, l) Any other(specify)
abdominal, joint
3 Patient signs at admission: Details of following Signs to be taken from the case sheet if the patient is admitted
a) Temperature b) Abnormal Lung X-Ray findings c) Coma(yes/no)
(yes/no)
d) Stridor (yes/ no) e) Tachypnoea(yes/no) f) Seizure(yes/no)
g) Redness of eyes (yes/no) h) Abnormal lung i) Any other(specify)
auscultation(yes/no)
4 Underlying medical conditions (tick all that apply)
a) COPD b) Hypertension c) Chronic neurological or
neuromuscular disease
d) Chronic Renal Disease e) Asthma f) Heart disease
g) Bronchitis h) Pregnancy j) Immunocompromised condition
i) (trimester) including HIV, TB
k) Malignancy l) Post-partum(< 6 m) Any other(mention)
weeks)
n) Diabetes o) Liver Disease p) None
D EXPOSURE HISTORY
5 Occupation (circle): Student/ Businessman/ Health care worker/Health care lab worker/ animal handler/ any other
(specify)………………………
6 H/O contact with COVID-19 case (Circle): Yes/ No
6.1 If yes, then was it any of the following (tick appropriate option)
a) laboratory confirmed case of COVID-19 b) person who is under investigation for COVID-19 while that person was ill

6.2 If yes to Q. 6, then mention contact setting (tick all that apply)
a) While taking samples/ other b) Visit to a place where COVID-19 cases are treated or sampled(specify
investigations detail)
c) Clinical care of case (among HCW) d) Immigration Staff at Point of Entry (details of place)
e) Housekeeping (Hospital) f) Others, Specify
 g) Caregiver of the case (specify details h) Not known
of case)
7 Is patient a member of a cluster of patients with severe acute respiratory illness (e.g., fever and pneumonia requiring
hospitalization) or COVID 19? (Yes/No)
8 Patient attended festival or mass gathering ?(Yes/No/Unknown) if yes, specify:

E TRAVEL HISTORY
10. Have you travelled outside India in the past one month? Yes/ No. If yes then fill details from Q. 10.1 onwards else skip to
Q.11
10.1
Name of the country (City) Date of arrival Date of departure

10.2 Did you visit Wuhan (yes/no) During your stay, did you visit any animal market? Yes/No

10.3 Date of arrival in India (Including transit flights in India): Flight No: Seat No:

11 Have you travelled within India in the past one month? Yes/ No. If no, skip to Section F
If yes, details of visit to other places: Names of places
a) Place & Duration of stay: Date of arrival: Mode of travel:

Date of departure: Details:

b) Place & Duration of stay: Date of arrival: Mode of travel:

Date of departure: Details:

c) Place & Duration of stay: Date of arrival: Mode of travel:

Date of departure: Details:

F LABORATORY INFORMATION (to be obtained from treating physician)

12 Details of sample collected for confirmation of COVID-19 case:
a)
Type of Name of sample Date of sample Sent to which Test Result
sample collection center collection Lab Performed
collected

b) Name of lab that confirmed result:

G PATIENT SYMPTOMS(Complication)
13a) Hospitalization(Yes/No)
b) ICU Admission(Yes/No)
Mechanical Ventilation(Yes/No)
ARDS (Yes/No)
Pneumonia by Chest X ray(Yes/No)
Consumptive coagulopathy( Yes/No)
Date of hospitalization:
Date of ICU admission : Date of discharge from ICU:
Date of mechanical ventilation Start:
Date of mechanical ventilation Stop:
Cardiac failure (Yes/No)
Acute Renal Failure (Yes/No)
Other complication (Yes/No), if yes please specify
 Sl.No.

Name

Age

Gender

Address

Phone

Relationship with the Contact

(Household contact/ Community/
Health care worker/ Co-traveller/
Others)

Type of Contact (High Risk/ Low Risk)

Tracked (Yes/ No)

District

State

Country of visit if any

Date of arrival from affected country,

if applicable

Date of last exposure

Observation started from

Contact tracing Linelist format

Symptomatic (Yes/No)

Date of onset of symptoms

Isolated (Home/Hospital) Pls specify

name of hospital

Sample taken Yes or no

Date of sample taken

Result- Pos/ Neg/ Pending

Date of completion of 28 days

observation period from the last
exposure

Today's Status (Currently admitted/

Home quarantined/ Migrated out/ Left
the country)

Date of Result

Remark

Lab where samples sent

 Case No - 65 yrs old male currently residing at XXXXXXXXXX

Singapore Airlines
Flight No: SQ XXX

15-03-2020 15-03-2020
01-03-2020 to Started from 15-03-2020
Change over at
14-03-2020 XXXXXXXX Reached Chennai
XXXXXXXXXXX airport at 10.00 PM
Stayed at reached
XXXXXXXXXX (2 hours)
XXXXXX airport Started to Chennai
at 06.00 PM at 08.20 PM
Reached home in Chennai
by own car driven by
personal driver

17-03-2020 17-03-2020 16-03-2020

01:00 PM Fore Noon 04.00 PM
Admitted in a XXXXX hospital Fever increased, Developed mild fever and
isolation ward in Chennai cough started cough.
Stayed at home

Reached private hospital by own

car, driven by personal driver
 Case History and Field Investigation Report
S.No. Information Details
1.1 Name
1.2 Age
1.3 Gender

1.4 Address

1.5 Occupation
1.6 Mobile Number
1.7 District
1.8 State
1.9 Nationality
2. Travel History
Travel to COVID-19 affected
2.1
country (Yes/No)
2.2 If Yes, name of the country
Date & Time of arrival in
2.3
India
2.4 Flight No
2.5 Seat No
3. Contact History
H/o contact with confirmed
3.1
COVID-19 case
H/o contact with person with
3.2
international travel history
3.3 H/o travel to nearby states
4. Medical history
Fever : __________
4.1 Date of onset of symptoms Cough/ Sore throat : __________
Breathing difficulty : ___________
4.2 Comorbidities (Yes/ No)
a. Diabetes
b. Hypertension
c. Bronchial Asthma
4.3
d. COPD
e. Immunosuppression drugs
f. Others
4.4 Date of isolation
4.5 Isolation facility
5. Sample Collection details
5.1 Date of sample collection
5.2 Sample collection centre
5.3 Sample tested at
5.4 Lab that confirmed the result
6. Treatment details

Outcome
6.1
(Admitted/Discharged/Death)
6.2 Clinical Condition
6.3 Date of outcome
7. Contact Tracing History
Is patient member of cluster
7.1
of COVID-19
7.2 Total Contacts Identified Tracked
7.2a High risk contacts
7.2b Low risk contacts
Is the person Health Care
7.3
Worker
8. Field activities
8.1 Field survey done (Yes/No)
Number of ILI cases identified
8.1a
in the locality
Any other hospital admission
for SARI (Severe Acute
8.1b
Respiratory Illness) in the
locality

8.2 Disinfection done (Yes/No)

9. Reporting format
Case Investigation Format
9.1 submitted to State EOC
(Yes/No)
Contact tracing line list
9.2 submitted to State EOC
(Yes/No)
Flowchart submitted to State
9.3
EOC (Yes/No)