Laboratory-confirmed COVID-19 Case and Death REPORT Card

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Use this online form to submit laboratory-confirmed (or pre-approved epidemiologically-linked) cases or 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. Complete the other fields when known. Public Health will follow-up with the reporter for the patient demographics and lab report, if missing.

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.

For all other reporters, please complete the requested information below.

Thank you!

REDCap Project

Date of Report:

M-D-Y

Reportable Disease/Health Condition:

* must provide value

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 one of the following:

close contact with a known case of COVID-19 disease
OR

a member of a risk cohort as defined by public health authorities during an outbreak (e.g., schools, universities, camps, long-term care facilities, correctional facilities, or childcare settings)

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Have you or your facility previously reported this as a laboratory-confirmed COVID-19 case?

* must provide value

Yes

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You have selected to report an individual with compatible COVID-19 symptoms AND close contact with a known case of COVID-19 disease or a member of a risk cohort as defined by public health authorities during an outbreak (e.g., schools, universities, camps, long-term care facilities, correctional facilities, or childcare settings). 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

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If yes, to which laboratory will you be submitting specimens?

* must provide value

ADPH Bureau of Clinical Laboratories

Commercial Laboratory

Clinical Laboratory / On-site

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If commercial or clinical / on-site, 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

Patient's Age (in years):

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If patient <18 years old, provide parent/proxy's name:

* must provide value

Is the patient deceased?

* must provide value

Yes

Unknown

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Patient's Date of Death:

* must provide value

M-D-Y

You have selected to report a Novel Coronavirus death to ADPH.

Please provide the following information in addition to the information entered on this REPORT Card:

⇒ Provide the following clinical information found in the patient's medical record:
✅ Facesheet (including patient demographics)
✅ History and physical
✅ Positive COVID-19 laboratory report
✅ Discharge summary (to include date and time of death)

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

Patient's Gender:

* must provide value

Patient's Race:

* must provide value

If patient's race is other, please specify:

Patient's Ethnicity:

* must provide value

Patient's Marital Status:

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

* must provide value

Patient's Street Address of Residence 1:

* must provide value

Patient's Street Address of Residence 2:

Patient's City of Residence:

* must provide value

Patient's State of Residence:

* must provide value

Patient's County of Residence:

* must provide value

Patient's Zip Code of Residence:

* must provide value

Patient's Payor Source:

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

Unknown

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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)

During this illness, did the patient experience any of the following symptoms?

Yes

Unknown

Cough (new onset or worsening of chronic cough)

* must provide value

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Fever (>=100.4)

* must provide value

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Fever, subjective

* must provide value

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Chills or rigors

* must provide value

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Muscle aches (myalgia)

* must provide value

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Shortness of breath (dyspnea)

* must provide value

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Wheezing

* must provide value

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Chest Pain

* must provide value

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Runny nose (rhinorrhea) or congestion

* must provide value

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Sore throat

* must provide value

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Headache

* must provide value

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New loss of smell or taste

* must provide value

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Diarrhea (>=3 loose/looser stools than normal in a 24-hour period)

* must provide value

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Abdominal pain or tenderness

* must provide value

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Persistent vomiting

* must provide value

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Fatigue

* must provide value

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Date of Onset:

M-D-Y

Date of COVID-19 Diagnosis:

M-D-Y

Is the patient hospitalized?

* must provide value

Yes

Unknown

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If yes, date of admission:

* must provide value

M-D-Y

Did patient develop pneumonia (clinical or X-ray diagnosed)?

Yes

Unknown

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Did patient have acute respiratory distress syndrome?

Yes

Unknown

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

Yes

Unknown

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If yes, please specify the alternative more likely diagnosis:

Is the patient pregnant?:

* must provide value

Yes

Unknown

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If yes, what is the completed gestational age (in weeks) of the baby?

* must provide value

Has the patient been diagnosed with any of the following underlying conditions?

Yes

Unknown

Body mass index (BMI) ≥30 kg/m² or obesity

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Cardiovascular disease

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Diabetes mellitus

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Was the specimen collected tested on-site at your facility?

NOTE: Only select "Yes" if the testing was performed in-house. If the specimen was sent off to another facility (e.g., clinical, commercial, or reference laboratory) to perform the testing, then select "No".

* must provide value

Yes

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If yes, which point-of-care or on-site platform was used to conduct the testing?

* must provide value

Specimen Collection Date:

M-D-Y

Performing Lab/Facility Name:

* must provide value

Performing Lab's/Facility's Accession Number:

What was the COVID-19 (SARS-CoV-2) result?

* must provide value

Detected/Positive

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What were the results?:

* must provide value

Influenza A virus detected

Influenza B virus detected

SARS coronavirus 2 detected

What were the results?:

* must provide value

Influenza A virus detected

Influenza B virus detected

Respiratory syncytial virus detected

SARS coronavirus 2 detected

Has the patient used any e-cigarette or vaping products in the past three months?

Yes

Unknown

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During incubation or infectious period, did patient work at, reside in, or visit a long-term care facility (LTCF)?:

Employee

Resident

Visitor

None

Unknown

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Was the patient a resident of a correctional facility at time of diagnosis?:

Yes

Unknown

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Is the patient associated with a school, university, daycare center, or camp?:

* must provide value

Yes

Unknown

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If yes, school/university/daycare center/camp name:

* must provide value

If yes, grade/year/shared location:

* must provide value

If yes, school/university/daycare center/camp name:

If yes, grade/year/classroom/shared location:

Has the patient or patient's proxy been notified by the reporter of this diagnosis or laboratory result?:

You may upload up to three laboratory reports and/or supporting documents for this death. Demographics must be included in any upload.

How many would you like to upload?:

Document/Result 1:

Upload file

Document/Result 2:

Upload file

Document/Result 3:

Upload file

Comments:

***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.

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Reporter Type or On Behalf Of:

* must provide value

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:

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 E-mail Address:

Reporter's Street Address:

Reporter's City:

Reporter's State:

Reporter's Zip Code:

* must provide value

Verify Information

Before submitting the REPORT Card, please review the summary below and verify it is accurate. If everything is correct, click the submit button below. Patient name, state, and county are required fields.

If you would like to print this disease/event report prior to submission, click Ctrl plus P on your keyboard.

Date of Submission	______
Disease/Condition	______
Reporter	______ ______, ______, ______
Patient	______ ______ (DOB: ______) / ______, ______

Is this patient prioritized for interview?

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Date/Time Supporting Documents Sent to Division:

M-D-Y H:M

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