KENYA CASE INVESTIGATION FORM By : Gertrude's Children's Hospital 01 November, 2020 Order Number Test Justification * Baseline Follow-up MINISTRY OF HEALTH Division of Disease Surveillance and Surveillance Case investigation form for 2019 Novel Coronavirus (COVID-19) Date of reporting to national level: * Why was the person tested for COVID-19 or investigation being conducted? * Contact with confirmed case Presented at health facility Point of entry detection Surveillance Repatriation Other Date of investigation: * Section 1: Patient information (All fields in this section must be filled in) 1.1 Unique Case Identifier (UHID) * 1.2 Full name: * 1.3 Nationality: * African Asian European/American Other 1.4 Citizenship: * 1.5 National ID/Passport Number: * 1.6 Age Age (years) Age (months) 1.7 Sex at birth: * Male Female 1.8 Place where the case was diagnosed: * Health Facility Household 1.8.1 If health facility, name of health facility: GERTRUDE’S CHILDREN’S HOSPITAL Contact Person: Dr. THOMAS NGWIRI 0733 753 650 Email:TNGWIRI@GERTIES.ORG Email results to:Dr. BEATRICE KABERA 0721 203 153 Email: BKABERA@GERTIES.ORG 1.8.2 Patient usual place of residence (village/estate): * Section 2: Clinical information Patient clinical course 2.1 Date of onset of symptoms: * Patient symptom * Symptomatic Asymptomatic Unknown 2.2 Admission to hospital: * No Yes Unknown 2.2.3 Patient taken to isolation: * No Yes Unknown 2.2.4 Patient admitted to ICU * No Yes Unknown 2.2.5 Was the patient ventilated: * No Yes Unknown 2.3 Health status at time of reporting: * Stable Severely ill Dead Unknown 2.3.1 Outcome * Still in hospital Discharged Dead 2.4 Patient symptoms (check all reported symptoms): * History of fever / chills Shortness of breath General weakness Diarrhoea Cough Nausea/vomiting Sore throat Headache Runny nose Headache Irritability/Confusion Pain Other, specify 2.4.1 Have the symptoms resolved? * Yes No Unknown Patient signs 2.5 Temperature ℃ 2.6 Check all observed signs: * Pharyngeal exudate Coma Abnormal lung X-Ray findings Conjunctival injection Dyspnea / tachypnea Conjunctival injection Seizure Abnormal lung auscultation Other, specify: 2.7 Underlying conditions and comorbidity (check all that apply): * Pregnancy (trimester: ) Cardiovascular disease, including hypertension Post-partum (< 6 weeks) Diabetes Renal disease Liver disease Chronic lung disease Chronic neurological or neuromuscular disease Malignancy Smoking (current or former smoker) Other, specify: Section 3: Exposure and travel information in the 14 days prior to symptom onset (prior to reporting if asymptomatic) 3.1 Occupation: (tick any that apply) * Student Health care worker, Cadre Working with animals Health laboratory worker Other, specify: 3.2 Has the patient travelled in the 14 days prior to symptom onset? * No Yes Unknown 3.3 Has the patient visited any health care facility(s) in the 14 days prior to symptom onset? * No Yes Unknown 3.4 Has the patient had close contact with a person with acute respiratory infection in the 14 days prior to symptom onset? * No Yes Unknown 3.5 Has the patient had contact with a probable or confirmed case in the 14 days prior to symptom onset? * No Yes Unknown Section 4: Laboratory Information Specimen collection (To be completed by the health facility) 4.1 Was specimen collected? * Yes No 4.2 Date(s) of specimen collection: * 4.3 Specimen type: * NP Swab OP Swab Serum Sputum Tracheal Aspirate Other (specify): 4.4 Date specimen send to the lab: * (To be completed by the laboratory confirming the test) 4.5 Date specimen received in the laboratory * Name of confirming lab: * 4.6 Please specify which assay was used: * 4.7 Preliminary lab results: * 4.8 Has sequencing been done? * Yes No Unknown 4.9 Date of laboratory confirmation: * print Share on Facebook Tweet this Share on LinkedIn Categories Blog Forms Hospital-Services News Latest Posts Dental Booking HPV Vaccine Booking COVID-19 Vaccination Technical Guidance Pfizer Vaccine Moderna Vaccination Booking COVID-19 Test Booking(PCR) AstraZeneca Vaccination Booking
