Swab No.

Coronavirus Disease (COVID-19)

Case Investigation Form
Philippine Integrated Disease Surveillance and Response
Disease Reporting Unit / Hospital: Reason for Testing: Name of Investigator: Date of Interview: ( ) RBR Subgroup ( A - J )
( ) ROF
VISIT TO BAGUIO ( ) RW
1. Patient Profile
Last Name First Name Middle Name Birthday Age
SALENGA JAN EIGBERT RAMOS SEPT. 26, 1993 27
Sex: (/) Male Civil Status Nationality PhilHealth No. Passport No.
() Female SINGLE FILIPINO N/A
2. Philippine Residence
2.1. Current Address
REGION Province Municipality/City Barangay House No. / Lot / Blk / Bldg. / Subd
III BATAAN DINALUPIHAN SAN RAMON Street & Purok
Email address Cellphone No. Home Phone No. #06 DIWA ST
ENDYINIRJAN26@GMAIL.COM 09772698528
Longitude Latitude
2.2. Permanent Address
REGION Province Municipality/City Barangay House No. / Lot / Blk / Bldg. / Subd
III BATAAN DINALUPIHAN SAN RAMON Street & Purok
Email address Cellphone No. Home Phone No.
ENDYINIRJAN26@GMAIL.COM 09772698528
3. Employment Information
Occupation Place of Work Employer's / Company Name
GOVT EMPLOYEE BURGOS-SOLIMAN, HERMOSA, BATAAN MUNICIPALITY OF HERMOSA
Employer's Email address Employer's Cellphone No. Employer's Phone No.
HERMOSABATAAN@YAHOO.COM N/A N/A
4. History of Travel
4.1 History of travel / visit / work outside of Baguio City ( ) Yes , Domestic Travel , Please fill out 4.2
( / ) Non-Baguio Resident
( ) No
4.2 For Baguio Residents Only with History of travel /visit / work in other areas with Place of Travel Date of Travel Duration of Travel
known COVID-19 transmission in the last 14 days
4.3 For Returning Overseas Filipinos History of travel / visit / work in other countries with known COVID- ( ) Yes Port (Country ) of exit:
19 transmission in the last 14 days ( ) No
Airline/Sea vessel: Flight/Vessel Number: Date of Departure Date of Arrival in Philippines:

5. Exposure History
History of Exposure to Known COVID-19 Case in the last 14 days If yes: Date of last contact with Known COVID-19 Case:
( ) Yes Initials of Known COVID-19 Case :
( / ) No Address of Known COVID-19 Case:
( ) Unknown
Have you been in a place with a known COVID-19 ( ) Yes If yes: Please check all that applies
transmission in the 14 days before this interview/onset of ( / ) No ( ) Household ( ) Health facility
symptoms ( ) Unknown ( ) Work place ( ) Religious gathering
( ) Transport ( ) Malls & Markets
( ) Social gathering ( Parties, etc.) ( ) Others: specify type:
List the names of persons who were with you two days prior to onset of illness until this Name Contact number
date and their contact numbers: 1.
Use the back part of this sheet when needed 2.
3.
6. Clinical Information
Disposition at Time of Report ( ) Outpatient ( ) Currently admitted ( ) In a quarantine or isolation facility ( ) Discharged
( ) Home-based isolation ( ) Died ( ) Others, please specify:
Health Status at time of Report / Severity ( ) Asymptomatic ( ) Mild disease ( ) Severe disease ( ) Critical ( ) Died
Smoking History ( ) Current Smoker ( ) Never Smoked ( ) Former Smoker
Date of Onset of Illness: Date of Admission / Consultation:
Place a mark on symptoms you are currently experiencing
( ) Fever Temperature °C ( ) Cough ( ) Sore throat ( ) Colds
Other signs/symptoms, specify: Is there any history of other illness? ( ) Yes ( ) No
If YES, specify:
Chest X-ray done? ( ) Yes ( ) No If yes, when? Are you pregnant? ( ) Yes ( ) No LMP:
CXR Results: Pneumonia ( ) Yes ( ) No ( ) Pending Other Radiologic Findings:
Assessed as High Risk : ( ) Yes ( ) No
7. Specimen Information
Specimen Collected If YES, Date and Time Collected Date Performed Date Release of Result Result
( ) Oropharyngeal Swab and Nasopharyngeal
Swab
( ) Oropharyngeal Swab
( ) Nasopharyngeal Swab
( ) Serum
( ) Antigen Testing
( ) Others
8. Classification
( ) Suspect Case ( ) Probable Case ( ) Confirmed Case ( ) Possible Case
9. Outcome
Date of Discharge: Condition on Discharge: ( ) Improved ( ) Recovered / Asymptomatic ( ) Transferred ( ) Absconded ( ) Died
Name of Informant: (if patient not available) Relationship: Phone No.

(/) I am authorizing the City Government of Baguio to inform me of my RT-PCR Test result through the cellphone number provided above. In
the absence thereof , I may be contacted through my authorized representative, RIO MAURICIO,through: Cellphone No.: 09276981752