Case report form for 2019 novel coronavirus
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Case report form for 2019 novel coronavirus

Filetype[PDF-47.68 KB]

  • English

  • Details:

    • Description:
      The Case Report Form is intended for local and state health departments who have a laboratory confirmed case of 2019-nCoV to report to CDC.

      2019 novel coronavirus (2019-nCoV) is a newly emerged coronavirus spreading from person-to-person. There is much to be learned about this illness. As cases are identified in the United States, CDC is working with state and local health departments to prevent further spread of 2019-nCoV and to collect information to better understand the virus. As part of this response, CDC has developed a case report form to assist our partners in characterizing laboratory-confirmed 2019-nCoV cases. The form provides a standardized approach to collecting data in order to track the outbreak, better characterize cases, and inform the public health response.

      The 2019-nCoV Case Report Form is designed to collect key information on laboratory-confirmed 2019-nCoV case-patients, including:

      • Demographic, clinical, and epidemiologic characteristics

      • Exposure and contact history

      • Course of clinical illness and care received

      The 2019-nCoV Case Report Form and supplement resources are available:

      • 2019-nCoV Case Report Form

      • 2019-nCoV Case Report Form Instructions

      • Data dictionary

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