Date of Report: Today M-D-Y MM/DD/YYYY
Reportable Disease/Health Condition:* must provide value
Novel Coronavirus (COVID-19)
The drop-down will auto-complete if needed.
What type of case are you trying to report?* must provide value
A laboratory-confirmed COVID-19 case
A laboratory-confirmed COVID-19 case who has died
An individual with compatible COVID-19 symptoms AND exposure to a known COVID-19 case (no laboratory testing performed)
You have selected to report an individual with compatible COVID-19 symptoms AND exposure to a known COVID-19 case (no laboratory testing performed) . Individuals should meet one of the following criteria and NOT have a more likely diagnosis other than COVID-19:
At least two of the following symptoms: fever (measured or subjective), chills, rigors, myalgia, headache, sore throat, nausea or vomiting, diarrhea, fatigue, congestion or runny nose OR At least one of the following symptoms: cough, shortness of breath, difficulty breathing, new olfactory disorder, or new taste disorder OR Severe respiratory illness with at least one of the following:Clinical or radiographic evidence of pneumonia or Acute respiratory distress syndrome (ARDS) Do you plan on testing the patient?* must provide value
Yes
No
If yes , to which laboratory will you be submitting specimens? * must provide value
ADPH Bureau of Clinical Laboratories
Commercial Laboratory
Clinical Laboratory
If commercial or clinical , please specify:* must provide value
Patient's First Name:* must provide value
Patient's Last Name:* must provide value
Patient's Phone Number:* must provide value
###-###-####
Patient's Date of Birth:* must provide value
M-D-Y MM-DD-YYYY
Patient's Age (in years): View equation
Calculated field
If patient <18 years old , provide parent/proxy's name:* must provide value
Is the patient deceased?* must provide value
Yes
No
Unknown
Patient's Date of Death:* must provide value
M-D-Y MM-DD-YYYY
You have selected to report a Novel Coronavirus death to ADPH. Patient's Gender:* must provide value
Female Male Unknown
Patient's Race:* must provide value
White Black or African American Asian American Indian or Alaskan Native Native Hawaiian or Other Pacific Islander Other Unknown
If patient's race is other , please specify:
Patient's Ethnicity:* must provide value
Hispanic or Latino Not Hispanic or Latino Unknown
Patient's Marital Status: Annulled Unmarried Common Law Divorced Separated Living Together Interlocutory Legally separated Married Polygamous Single, never married Domestic partner Widowed Other Unreported Refused to answer Unknown
Which would best describe where the patient was staying at the time of illness onset?:* must provide value
Acute care inpatient facility Apartment Correctional facility Group home Homeless shelter Hotel/motel House/single family home Long term care facility Mobile home Outside, in a car, or other location not meant for human habitation Rehabilitation facility Other Unknown
Patient's Street Address of Residence 1:* must provide value
123 Main St
Patient's Street Address of Residence 2: P.O. Box or Long-term Care Facility, Correctional Facility, or Shelter Name
Patient's City of Residence:* must provide value
Patient's State of Residence:* must provide value
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Johnston Atoll Marshall Islands Northern Mariana Islands Palau Midway Islands Puerto Rico U.S. Minor Outlying Islands Navassa Island Virgin Islands of the U.S. Wake Island Baker Island Howland Island Jarvis Island Kingman Reef Palmyra Atoll
Patient's County of Residence:* must provide value
Autauga County Baldwin County Barbour County Bibb County Blount County Bullock County Butler County Calhoun County Chambers County Cherokee County Chilton County Choctaw County Clarke County Clay County Cleburne County Coffee County Colbert County Conecuh County Coosa County Covington County Crenshaw County Cullman County Dale County Dallas County De Kalb County Elmore County Escambia County Etowah County Fayette County Franklin County Geneva County Greene County Hale County Henry County Houston County Jackson County Jefferson County Lamar County Lauderdale County Lawrence County Lee County Limestone County Lowndes County Macon County Madison County Marengo County Marion County Marshall County Mobile County Monroe County Montgomery County Morgan County Perry County Pickens County Pike County Randolph County Russell County Saint Clair County Shelby County Sumter County Talladega County Tallapoosa County Tuscaloosa County Walker County Washington County Wilcox County Winston County
Complete if Alabama resident.
Patient's Zip Code of Residence:* must provide value
##### or #####-####
Patient's Payor Source: Indian Health Service (IHS) Medicaid/state assistance program Medicare Military/VA Private/HMO/PPO/Managed care plan No health care coverage Other Unknown
If patient's payor source is other , please specify:
Did patient experience any COVID-19 compatible symptoms during his/her illness?* must provide value
Yes
No
Unknown
During this illness, did the patient experience any of the following symptoms?
Date of Onset: M-D-Y MM-DD-YYYY
Date of COVID-19 Diagnosis: M-D-Y MM-DD-YYYY
Is the patient hospitalized?* must provide value
Yes
No
Unknown
If yes , date of admission:* must provide value
M-D-Y
Did patient develop pneumonia (clinical or X-ray diagnosed)?* must provide value
Yes
No
Unknown
Did patient have acute respiratory distress syndrome?* must provide value
Yes
No
Unknown
Did the patient have an alternative more likely diagnosis/etiology for their illness?* must provide value
Yes
No
Unknown
If yes , please specify the alternative more likely diagnosis:* must provide value
Is the patient pregnant?:* must provide value
Yes
No
Unknown
Has the patient been diagnosed with any of the following underlying conditions?
Date of Laboratory Results: M-D-Y MM-DD-YYYY
Performing Lab Name:
Performing Lab's Accession Number:
Qualitative Results: Detected
Not Detected
Indeterminate
Inconclusive
Invalid
Unsatisfactory
During incubation or infectious period, did patient work at, reside in, or visit a long-term care facility (LTCF)?: * must provide value
Employee
Resident
Visitor
None
Unknown
Was the patient a resident of a correctional facility at time of diagnosis?:* must provide value
Yes
No
Unknown
Is the patient associated with a school, university, or daycare center?:* must provide value
Yes
No
Unknown
If yes , school/university/daycare center name:* must provide value
If yes , grade/year/class:
Has the patient or patient's proxy been notified by the reporter of this diagnosis or laboratory result?: * must provide value
Yes No Unknown
You may upload up to three laboratory reports and/or supporting documents for this patient. Demographics must be included in any upload.* must provide value
0 1 2 3
Document/Result 1:
Document/Result 2:
Document/Result 3:
Reporter Type or On Behalf Of:* must provide value
Blood bank Correctional institution Day care center (environment) Dentist Drug treatment facility Emergency room Family planning facility Federal agency HIV care facility HIV counseling and testing site Hospital Laboratory Labor and delivery Managed care or health maintainence organization Mental health provider Military (organization) National Job Training Program Pharmacy Prenatal and or obstetrics facility Private physicians group office (environment) Public health clinic Registries Rural health STD clinic Student health TB clinic Tribal government United States Indian Health Service Vital statistics Veterinary source Other Other health department clinic Other state and or local agencies Other treatment center Unknown
If you are a laboratorian , reporting on behalf of a laboratory , blood bank , or plasma center the REPORT Card is not the mechanism you should use to report a patient that has a reportable disease or health condition. Please email mu.elr@adph.state.al.us to learn more. Reporter's Facility Name:* must provide value
Investigator Type Code: HIDDEN FIELD
Reporter's First Name:* must provide value
Reporter's Last Name:* must provide value
Reporter's Phone Number:* must provide value
###-###-####
Reporter's Alternate/After-Hours Phone Number: ###-###-####
Reporter's Street Address: 123 Main St
Reporter's City:
Reporter's State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Johnston Atoll Marshall Islands Northern Mariana Islands Palau Midway Islands Puerto Rico U.S. Minor Outlying Islands Navassa Island Virgin Islands of the U.S. Wake Island Baker Island Howland Island Jarvis Island Kingman Reef Palmyra Atoll
Reporter's Zip Code: ##### or #####-####
Verify Information Patient name, state, and county are required fields. Ctrl plus P on your keyboard. Date of Submission ______ Disease/Condition ______ Reporter ______ ______ , ______ , ______ Patient ______ ______ (DOB: ______ ) / ______ , ______
Is this patient prioritized for interview? View equation
1=Yes, 0=No
Date/Time Supporting Documents Sent to Division: Now M-D-Y H:M
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