COVID-19 CASE INVESTIGATION FORM

1
Facility Name _________________________________________________
2 Date of case report To be generated by the eIDSR system
3 Are you reporting during an outbreak □Yes □No
4 If outbreak, outbreak code To be generated by the eIDSR system

SECTION 1: PATIENT INFORMATION

Patient local registration No.
5

6 Patient unique ID To be generated by the eIDSR system

Last name:
_________________________________________________
7 Patient name
First name:
_________________________________________________
8 Date of birth (dd/mm/yyyy) _____/______/_____
9 Age in years To be generated by the eIDSR system
Male □
10 Sex at birth
Female □
Alive □
11 Patient status at time of this report
Dead □
12 Mobile number (Contact Number) ______________________________
WhatsApp/WeChat Number ______________________________
13 In Rwanda □
Residence
Outside Rwanda □

14 If residence in Rwanda, precise location _________/___________/__________/__________/_______

Province / District / Sector / Cell / Village

If residence outside Rwanda, specify

15 ________________________________
country
SECTION 2: CLINICAL SIGNS AND SYMPTOMS
Date of initial onset of symptoms
17 _____/______/_____
(dd/mm/yyyy)
In Rwanda □
16 Location where patient became ill Outside Precise
□ country___________________________
Rwanda

18 Date of initial consultation (dd/mm/yyyy) _____/______/_____

Fever
□Y □N □Unk
Record Temp _____oC
Cough □Y □N □Unk
Read each one aloud and tick an answer Shortness of Breath □Y □N □Unk
for all symptoms that occurred within the Sore throat □Y □N □Unk
last 14 days
Chills □Y □N □Unk
19
Headache □Y □N □Unk
Muscles ache □Y □N □Unk
Vomiting/nausea □Y □N □Unk
Abdominal pain □Y □N □Unk
Diarrhoea □Y □N □Unk
Other specify __________________________________

www.rbc.gov.rw / Info@rbc.gov.rw / PoBox : 7162 Kigali Rwanda

SECTION 3: OTHER CO-MORBIDITIES

Cardiovascular Disease □Y □N □Unk

Asthma □Y □N □Unk
Chronic Respiratory Disease □Y □N □Unk
Diabetes □Y □N □Unk
Chronic Liver Disease □Y □N □Unk
Check all comorbidity conditions that the Chronic Kidney Disease □Y □N □Unk
20 HIV □Y □N □Unk
patient has
Pregnancy □Y □N □Unk
Hypertension □Y □N □Unk
Tuberculosis □Y □N □Unk
Malnutrition □Y □N □Unk
Cancer □Y □N □Unk
Other(specify) ______________________
SECTION 4: EPIDEMIOLOGICAL RISK FACTORS AND EXPOSURES
Did the patient travel to ANY of the □Y □N
affected countries with local COVID-19
21 If yes, which
transmission (see annex for list) in the Date of travel____/____/2020
Country____________________
past 14 days before symptom onset?
Has the patient had any close contact (see annex)
with a suspected or confirmed case of COVID-19 □Y □N □Unk
within the last 14 days?

22 Has the patient had direct contact (see annex) with

sick or dead animals, animal markets or
consumed any animal products within the last 14 □Y □N □Unk
days?

□ Farmer
□ Butcher
□ Airline/Airport worker
□ Business person
□ Veterinarian
□ Animal Culler
□ Miner
23 Patient’s Occupation (check all that apply) □ Traditional Healer
□ Healthcare worker
If Healthcare worker, Function: _______________________

Healthcare facility: _________________________________

Other(specify):________________________________________
Has the patient visited or been admitted
to a healthcare facility in a country with
known COVID-19 patients? OR

Come into contact a person who works at

a healthcare worker who works at a
24 □Y □N □Unk
facility with known COVID-19 cases in the
past 14 days?

Does the patient have history of being in a

health care facility (as a visitor, patient or
worker) in China?

25 Case classification at the end of investigation

□ Suspect

SECTION 5: CLINICAL SPECIMENS

26 Has sample been taken? □Yes □No

To be generated on the form
27 Patient unique ID
28 Type of sample Nasal-pharyngeal (NP) □
Oral-phayngeal (OP) □
Both NP & OP □
Sputum □

www.rbc.gov.rw / Info@rbc.gov.rw / PoBox : 7162 Kigali Rwanda

 Tracheal aspirate □
Serum □
□ Specify:
Other specimen types, ______________________

29 Date of sample collection _____/______/________

30 Date sample sent to the Laboratory _____/______/________

SECTION 6: LABORATORY TESTING

31 Patient unique ID To be generated on the form

32 Lab result ID To be generated by the lab

33 Date sample received _____/______/_______

Yes □
34 Specimen accepted
No □
35 If No, reason for rejection

Sequencing □
PCR □
36 Lab test
Culture
Other(specify)……………………
Not
Test Pos Neg Pending
done
Novel coronavirus
Influenza A
Influenza B
SARS-CoV
MERS-CoV
37 Respiratory Diagnostic Results Adenovirus
RSV
H.Metapneumovirus
Rhinovirus
ParaInfluenza(1-4)
M.Pneumoniae
C.Pneumoniae
Other(specify)
SECTION 7: PATIENT OUTCOME INFORMATION
38 Patient Outcome □ Alive & Recovered □ Dead □ Lost to follow up
Health facility/isolation facility discharged from :
_____________________________________
If the patient recovered and
39 discharged from the health
facility/isolation facility Date of discharge from the health facility/isolation facility (dd/mm/yyyy):
______/_______/_______

40 If dead, date of death (dd/mm/yyyy) ______/______/________

□ Community
41 Place of death □ Health center
□ Hospital (DH/RH/PH)
□ Point Of Entry
SECTION 8: INVESTIGATION FORM COMPLETED BY
At KIA, the case investigation form Names: ____________________________________
was completed by Date:____/____/2020
Function: ___________________________________
Phone number: _______________________________
Email:_____________________________________
At Health Centre, the case Names: ____________________________________
investigation form was completed Date:____/____/2020
by Function: ___________________________________
Phone number: _______________________________

www.rbc.gov.rw / Info@rbc.gov.rw / PoBox : 7162 Kigali Rwanda


At Hospital, the case investigation
form was completed by
Email:_____________________________________
Names: _____ _______________________________
Date:____/____/2020
Function: ___________________________________
Phone number: _______________________________
Email:_____________________________________

Information provided by □ Patient If representative, specify the name and relationship

□ Representative _______________________________________

www.rbc.gov.rw / Info@rbc.gov.rw / PoBox : 7162 Kigali Rwanda