COVID-19 LTC Investigation Form

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Required format:

REDCap is a secure web application for managing online surveys and databases. While REDCap can be used to collect virtually any type of data in any environment including compliance with 21 CFR Part 11, FISMA, HIPAA, and GDPR.

Use this online form to submit laboratory-confirmed hospitalizations and deaths of Novel Coronavirus (COVID-19) to the Alabama Department of Public Health. All required fields are marked with a red asterisk (*); it is not possible to submit the report without completing all required fields. Public Health will follow-up with the reporter for the patient demographics and lab report, if missing.

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Condition code

Reporting Facility Name:

* must provide value

Other (specify):

* must provide value

Facility Address:

* must provide value

City:

* must provide value

State:

* must provide value

County:

* must provide value

Zip Code:

* must provide value

Facility Phone Number:

* must provide value

Interview Proxy Name and Title:

* must provide value

Email address:

* must provide value

Date of Report:

* must provide value

M-D-Y

Case's First Name:

* must provide value

Case's Last Name:

* must provide value

______'s DOB:

* must provide value

M-D-Y

______'s Reported Age:

______'s Sex:

* must provide value

Female Male

______'s Ethnicity:

* must provide value

Hispanic or Latino

Not Hispanic or Latino

Unknown

______'s Race:

* must provide value

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Other

Unknown

Does ______ have any tribal affiliation?

* must provide value

Yes No Unknown

If yes, which tribe(s)?

* must provide value

If yes, enrolled member?

* must provide value

Yes No Unknown

Please select the case's affiliation with your facility:

* must provide value

Employee

Resident

Vendor/Contractor

Visitor

Other

Other (specify):

* must provide value

Date of most recent admission:

* must provide value

M-D-Y

______'s Home Address:

* must provide value

______'s City:

* must provide value

______'s State:

* must provide value

______'s County:

* must provide value

______'s Zip Code:

* must provide value

______'s Phone Number:

* must provide value

Did ______ experience any symptoms during his/her illness?

* must provide value

Yes No Unknown

When did ______ first feel ill (onset date)?

* must provide value

M-D-Y

Is ______ still feeling ill?

* must provide value

Yes No Unknown

If no, when did ______ feel better?

* must provide value

M-D-Y

Which signs and/or symptoms has ______ had since ______?

Fever (>=100.4):

* must provide value

Yes No Unknown

Subjective fever:

* must provide value

Yes No Unknown

New uncontrolled cough that causes difficulty breathing:

* must provide value

Yes No Unknown

Shortness of breath:

* must provide value

Yes No Unknown

Chest pain:

* must provide value

Yes No Unknown

Muscle Aches:

* must provide value

Yes No Unknown

Fatigue:

* must provide value

Yes No Unknown

Chills/Rigors:

* must provide value

Yes No Unknown

Congestion/Runny nose:

* must provide value

Yes No Unknown

Sore throat:

* must provide value

Yes No Unknown

New loss of smell of taste:

* must provide value

Yes No Unknown

Vomiting:

* must provide value

Yes No Unknown

Headache:

* must provide value

Yes No Unknown

Abdominal pain or tenderness:

* must provide value

Yes No Unknown

Diarrhea:

* must provide value

Yes No Unknown

Other:

Which would best describe where the patient was staying at the time of illness onset?

* must provide value

If other, specify housing:

* must provide value

Pneumonia (clinical or X-ray diagnosed):

* must provide value

Yes No Unknown

Acute respiratory distress syndrome:

* must provide value

Yes No Unknown

Abnormal chest x-ray:

* must provide value

Yes No Unknown

Did ______ have an alternative more likely diagnosis/etiology for their illness?

* must provide value

Yes No Unknown

Other Etiology (specify):

* must provide value

Current Smoker:

* must provide value

Yes No Unknown

Former Smoker:

* must provide value

Yes No Unknown

Diabetes Mellitus:

* must provide value

Yes No Unknown

Chronic Lung Disease (asthma/emphysema/COPD):

* must provide value

Yes No Unknown

Cardiovascular Disease:

* must provide value

Yes No Unknown

Chronic Renal Disease:

* must provide value

Yes No Unknown

Chronic Liver Disease:

* must provide value

Yes No Unknown

Autoimmune condition:

* must provide value

Yes No Unknown

Which autoimmune condition does ______ have?

* must provide value

Hypertension:

* must provide value

Yes No Unknown

Severe obesity (BMI >= 30):

* must provide value

Yes No Unknown

Substance abuse or misuse:

* must provide value

Yes No Unknown

Disability (neurologic, neurodevelopmental, intellectual, physical, vision or hearing impairment):

* must provide value

Yes No Unknown

If yes, specify:

* must provide value

Psychological/psychiatric condition:

* must provide value

Yes No Unknown

If yes, specify:

* must provide value

Is ______ immunocompromised?

* must provide value

Yes No Unknown

Specify the immunosuppressive condition(s):

* must provide value

Did ______ have an abnormal EKG?

* must provide value

Yes No Unknown

Was ______ hospitalized at the time of illness onset?

* must provide value

Yes No Unknown

Is ______ pregnant?

* must provide value

Yes No Unknown

Other underlying condition or risk behavior:

* must provide value

Yes No Unknown

If yes, specify:

* must provide value

Has ______ been tested for COVID-19?

* must provide value

Yes No Unknown

Was the POSITIVE clinical specimen tested on-site or sent to a reference lab?

* must provide value

On-site

Reference laboratory

Please provide the laboratory name:

* must provide value

Please provide the test type performed at the reference lab:

*A PCR test detects the viral RNA of SARS-CoV-2.
*An antigen test detects specific proteins on the surface of SARS-CoV-2.

* must provide value

PCR/NAAT

Antigen

Unsure

Please select the testing platform used:

* must provide value

Quidel Sofia 2 SARS Antigen FIA

Abbott BinaxNOW

LumiraDx SARS-CoV-2 Ag

BD Veritor™ Plus System for rapid COVID-19 (SARS-CoV-2) testing

JOYSBIO COVID-19 Antigen Rapid Test Kit [Colloidal Gold] (Antigen)

INDICAID COVID-19 Rapid Antigen Test (Antigen)

Celltrion DiaTrust COVID-19 Ag Rapid Test (Antigen)

iHealth COVID-19 Antigen Rapid Test (Antigen)

Date of Specimen collection

* must provide value

M-D-Y

Specimen Source

* must provide value

Nasal swab

Nasopharyngeal swab

Is this the first time ______ was tested?

* must provide value

Yes No Unknown

Was the patient fully vaccinated against COVID-19?

A breakthrough case is defined as a U.S. resident who has SARS-CoV-2 RNA or antigen detected on a respiratory specimen ≥ 14 days after completing the primary series of an FDA-authorized COVID-19 vaccine (e.g., two does of the Moderna or Pfizer vaccine, or a single dose of the Janssen vaccine).

* must provide value

Yes

No

Unknown

Is the patient you are reporting a U.S. resident?

* must provide value

Yes

No

Unknown

Was the primary FDA-authorized COVID-19 vaccine series completed? (e.g., the patient received two doses of the Moderna or Pfizer vaccine, or a single dose of the Janssen vaccine).

* must provide value

Yes

No

Did the patient have a positive SARS-CoV-2 test at least 14 days after completion of the vaccine series?

* must provide value

Yes

No

Did the patient have a history of a positive SARS-CoV-2 test less than 45 days prior to current positive test?

* must provide value

Yes

No

Unknown

Date of last COVID-19 vaccination:

* must provide value

M-D-Y

✅ This patient meets the criteria for a COVID-19 vaccine breakthrough case. ADPH will follow up with the reference lab regarding specimen submission to the Bureau of Clinical Laboratories.

❌ This patient does not meet the criteria for a COVID-19 vaccine breakthrough case or further testing.

Reviewed by Central Office Staff:

* must provide value

Yes

No

Comments about COVID-19 vaccine breakthrough case:

* must provide value

Expand

You may upload up to three laboratory reports and/or supporting documents for this patient. Please provide the following information found in the patient's medical record:

✅ Positive COVID-19 laboratory report

If the requested documents are not uploaded with this submission, someone from ADPH will be in touch with the reporter shortly to collect the additional information.

How many would you like to upload?

* must provide value

Document/Result 1:

Document/Result 2:

Document/Result 3:

Enter Cluster Code:

You may use this field to include any general comments about the case:

***Please do not use ampersands (& symbol) or carraige returns (i.e. pressing the enter button to start a new paragraph) when entering into this field.

Expand

Is ______ deceased?

* must provide value

Yes No Unknown

Date of death:

* must provide value

M-D-Y

Was ______ hospitalized for this illness?

* must provide value

Yes No Unknown

Hospital Name:

* must provide value

Other (specify):

* must provide value

City:

* must provide value

State:

* must provide value

County:

* must provide value

Other County:

* must provide value

Admission Date:

* must provide value

M-D-Y

Discharge Date:

M-D-Y

Was ______ admitted to an intensive care unit?

* must provide value

Yes No Unknown

Did ______ receive ECMO?

* must provide value

Yes No Unknown

Did ______ receive mechanical ventilation/intubation?

* must provide value

Yes No Unknown

Number of days with mechanical ventilation:

* must provide value

Was there a second hospitalization?

* must provide value

Yes No Unknown

Hospital Name:

* must provide value

Other (specify):

* must provide value

Admission Date:

* must provide value

M-D-Y

During the 14 days before illness onset or positive specimen collection date (for asymptomatic residents), did ______ reside in a LTCF?

* must provide value

Is this facility the same as the reporting facility?

* must provide value

Please select the name of the other LTCF the patient resided in:

* must provide value

Date of Admission:

* must provide value

M-D-Y

Date of Discharge:

* must provide value

M-D-Y

During the 14 days before illness onset or positive specimen collection date (for asymptomatic residents), did ______ stay in a hospital?

* must provide value

Yes No Unknown

Hospital Name:

* must provide value

Other (specify):

* must provide value

City:

* must provide value

State:

* must provide value

County:

* must provide value

Other, specify:

* must provide value

Admission Date:

* must provide value

M-D-Y

Discharge Date:

* must provide value

M-D-Y

During the 14 days before illness onset or positive specimen collection date (for asymptomatic residents), did ______ visit a healthcare clinic?

* must provide value

Yes No Unknown

Date of Visit:

* must provide value

M-D-Y

Healthcare Clinic Name:

* must provide value

City:

* must provide value

State:

* must provide value

County:

* must provide value

Other, specify:

* must provide value

Is ______ a close contact to a COVID-19 case?

* must provide value

Yes No Unknown

Is ______ epi-linked to a person suspected of having COVID-19?

* must provide value

Yes No Unknown

Is ______ epi-linked to a geographical area with at least one case of COVID-19?

* must provide value

Yes No Unknown

Did ______ attend a gathering of more than 10 people?

* must provide value

Yes No Unknown

Details of conference or gathering:

* must provide value

Did ______ have an exposure to an animal with confirmed or suspected COVID-19?

* must provide value

Yes No Unknown

If yes, specify the type of animal:

* must provide value

Please include any general comments here

***Please do not use ampersands (& symbol) or carraige returns (i.e. pressing the enter button to start a new paragraph) when entering into this field.

Expand

Use the time frame below to answer the following questions.

Infectious Period From: Illness onset date minus 2 days. (For asymptomatic residents, 2 days prior to positive specimen collection)

Infectious Period To: 10 days after illness onset, or specimen collection date if the person never experienced any symptoms. If the person is severely immunocompromised or severely ill, then isolation may continue up to 20 days.

While infectious, did ______ encounter any first responders, like ambulance, paramedics, police?

* must provide value

Yes No Unknown

Date of Exposure:

* must provide value

M-D-Y

Ambulance Service, Hospital, or Department Name

* must provide value

County:

* must provide value

Before submitting the COVID-19 LTC Investigation Form, please review the summary below and verify it is accurate. If everything is correct, click the submit button below and continue to enter the rest of the POSITIVE cases associated with your facility.

Date of Submission	______
Reporter and Facility Information	______, ______, ______
Case Information	______ ______ (DOB: ______)

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To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.