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last updated: 06.28.20 12:38p  + FHIR + CDC valuesets

CDC Interim Guidance on Developing a COVID-19
Case Investigation & Contact Tracing Plan [06.19.20 3:35pm]

Appendix C - Data Elements for Case Investigation and Contact Tracing Forms

Case Investigation
Data Element	Type	Codes	Notes
Locating Information
Investigator	Open Text		Name of investigator
Investigator ID	Numeric
Date Assigned for Investigation	Date
Index patient ID	Numeric		Autogenerated
Lot Number (to link related cases and contacts)	Numeric		To track clusters
Patient Last Name	Open Text
Patient First Name	Open Text
Patient Preferred Name	Open Text
DOB	Date
Gender	Categorical	M/F/Other/Unk
Primary Language	Open Text/ Categorical
Interpreter used	Categorical	Y/N/U/R
Residential Street Address	Open Text
City of Residence	Open Text
County of Residence	Open Text
State of Residence	Open Text
Zip code	Numeric
Tribal Affiliation	Open Text
Born in the United States	Categorical	Y/N/U/R
Phone Number 1	Numeric
Phone Number 2	Numeric
Email 1	Open Text
Email 2	Open Text
Ok to Text	Categorical	Yes, No, Partial, Refused
Ok to Email	Categorical	Yes, No, Partial, Refused
Race	Categorical	Check all apply	Use Census or HHS categories
Ethnicity	Categorical	Check box	Use Census or HHS categories
Date of interview Attempt 1	Date
Interview 1 occurred	Categorical	Yes, No, Partial, Refused
Date of interview Attempt 2	Date
Interview 2 occurred	Categorical	Yes, No, Partial, Refused
Date of interview Attempt 3	Date
Interview 3 occurred	Categorical	Yes, No, Partial, Refused
Symptoms and Clinical Course
Fever	Categorical	Check Box (Y/N/U/R)
Cough	Categorical	Check Box (Y/N/U/R)
Shortness of Breath	Categorical	Check Box (Y/N/U/R)
Diarrhea/GI	Categorical	Check Box (Y/N/U/R)
Headache	Categorical	Check Box (Y/N/U/R)
Muscle ache	Categorical	Check Box (Y/N/U/R)
Chills	Categorical	Check Box (Y/N/U/R)
Sore throat	Categorical	Check Box (Y/N/U/R)
Vomiting	Categorical	Check Box (Y/N/U/R)
Abdominal Pain	Categorical	Check Box (Y/N/U/R)
Nasal congestion	Categorical	Check Box (Y/N/U/R)
Loss of sense of smell	Categorical	Check Box (Y/N/U/R)
Loss of sense of taste	Categorical	Check Box (Y/N/U/R)
Malaise	Categorical	Check Box (Y/N/U/R)
Fatigue	Categorical	Check Box (Y/N/U/R)
Other symptom	Categorical
Other symptom description	Open Text
Date of symptom onset	Date
SARS-CoV-2 testing	Categorical	Check Box (Y/N/U/R)
Date of first SARS-CoV-2 test	Date
Results of first SARS-CoV-2 test	Categorical	Pos/Neg/Equi/Unk
Date of last SARS-CoV-2 test	Date
Results of last SARS-CoV-2 test	Categorical	Pos/Neg/Equi/Unk
Hospitalized	Categorical	Yes, No, Partial, Refused
Pneumonia	Categorical	Yes, No, Partial, Refused
ECMO
ICU	Categorical	Yes, No, Partial, Refused
Death	Categorical	Yes, No, Partial, Refused
Stroke	Categorical	Yes, No, Partial, Refused
MI	Categorical	Yes, No, Partial, Refused
Pre-existing conditions
Chronic lung disease	Categorical	Yes, No, Partial, Refused
Diabetes	Categorical	Yes, No, Partial, Refused
Severe Obesity (BMI>=40)	Categorical	Yes, No, Partial, Refused
CVD	Categorical	Yes, No, Partial, Refused
Chronic renal disease	Categorical	Yes, No, Partial, Refused
Chronic liver disease	Categorical	Yes, No, Partial, Refused
Immunocompromised	Categorical	Yes, No, Partial, Refused
Pregnant (if Female)	Categorical	Yes, No, Partial, Refused
Risk Factors
Contact with confirmed  COVID case	Categorical	Y/N/U/R
Employed	Categorical	Yes/No-unemployed/
		No-retired/No-unable to work/No-student
If employed, what occupation	Open text
If employed, what kind of workplace	Open text
HCP	Categorical	Y/N/U/R	Work or volunteer in a healthcare setting
If HCP, what kind of setting
Hospital	Categorical	Check box
Ambulatory care	Categorical	Check box
EMS/Fire/Law Enforcement/ 1st responder	Categorical	Check box
Urgent care	Categorical	Check box
Long term care	Categorical	Check box
Hospice	Categorical	Check box
Name of HCP setting	Open Text
Address of HCP setting	Open Text
Congregate setting	Categorical	Y/N/U/R	Do you live or work in congregate setting
If Congregate, what kind
Corrections	Categorical	Check box
Dorm	Categorical	Check box
Group home	Categorical	Check box
Multi-family household	Categorical	Check box
Multi-generational household	Categorical	Check box
Name of congregate setting	Open Text
Address of congregate setting	Open Text
Contact Tracing (during contact elicitation window)
Any household contact	Categorical	Y/N/U/R
Total Number of household contacts	Numeric
Can you self-isolate	Categorical	Y/N/U/R	Add in script what this means (use of bedroom and bathroom away from others)
Do you need assistance to  self-isolate	Categorical	Y/N/U/R
Any intimate partners	Categorical	Y/N/U/R	Partners you do not reside with
Total Number of Intimate Partners	Numeric
Any other people in closecontact with, including coworkers	Categorical	Y/N/U/R
Contact Elicitation Investigation
Data Element	Type	Codes	Notes
Index Information			Collected on the index
Investigator	Open Text		Name of investigator
Investigator ID	Numeric
Date Assigned for Investigation	Date
Index patient ID	Numeric		Autogenerated
Lot Number	Numeric		To track clusters
Date of contact elicitation	Date
Start date of Contact Elicitation	Date
Window
End date of Contact Elicitation	Date
Window
Information about contacts			Ask for each identified contact
Contact Last Name	Open Text
Contact First Name	Open Text
Contact AKA	Open Text
Contact Phone 1	Open Text
Contact Phone 2	Open Text
Contact email 1	Open Text
Contact email 2	Open Text
Contact social media handle 1	Open Text		Twitter, Grindr, etc.
Contact social media handle 2	Open Text
Contact Address	Open Text
Contact setting	Check all that apply
Home	Check box
School	Check box
Day Care	Check box
Workplace	Check box		includes customers/clients/clients and coworkers
Place of Worship	Check box
Shelter	Check box
Hospital/Medical Care	Check box
Travel or Transit	Check box
Retail setting	Check box		includes, supermarkets, gas stations, farmers markets, etc.
Duration of Exposure (minutes)	Numeric
Pre-existing conditions			If known
Chronic lung disease	Categorical	Y/N/U/R
Diabetes	Categorical	Y/N/U/R
Severe Obesity (BMI>=40)	Categorical	Y/N/U/R
CVD	Categorical	Y/N/U/R
Chronic renal disease	Categorical	Y/N/U/R
Chronic liver disease	Categorical	Y/N/U/R
Immunocompromised	Categorical	Y/N/U/R
Pregnant (if Female)	Categorical	Y/N/U/R
Risk Factors			If known
HCP	Categorical	Y/N/U/R	Work or volunteer in a healthcare setting
If HCP, what kind of setting
Hospital	Categorical	Check box
Ambulatory care	Categorical	Check box
EMT/Fire/1st responder	Categorical	Check box
Urgent care	Categorical	Check box
Long term care	Categorical	Check box
Hospice	Categorical	Check box
Congregate setting	Categorical	Y/N/U/R	Do you live or work in congregate setting
If Congregate, what kind
Corrections	Categorical	Check box
Dorm	Categorical	Check box
Group home	Categorical	Check box
Multi-family household	Categorical	Check box
Multi-generational household	Categorical	Check box
Community Settings
Travel risk	Categorical	Y/N/U/R	Train, plane, public transit
Specify travel	Open Text		List specific flights, routes, etc.
Workplace	Categorical	Y/N/U/R
Specify workplace	Open Text		Specific work locations
Retail	Categorical	Y/N/U/R
Specify retail	Open Text
Large community social event	Categorical	Y/N/U/R
Specify	Open Text
Recreational activity	Categorical	Y/N/U/R
Specify	Open Text
Places of Worship	Categorical	Y/N/U/R
Specify	Open Text
Contact Investigation
Data Element	Type	Codes	Notes
Locating Information
Investigator	Open Text		Name of investigator
Investigator ID	Numeric
Date Assigned for Investigation	Date
Index patient ID	Numeric		Autogenerated
Lot Number	Numeric		To track clusters
Contact patient ID	Numeric
Contact Last Name	Open Text
Contact First Name	Open Text
Contact Preferred Name	Open Text
DOB	Date
Gender	Categorical	M/F/Other/Unk
Primary Language	Open Text/ Categorical
Interpreter used	Categorical	Y/N/U/R
Residential Street Address	Open
City of Residence	Open Text
County of Residence	Open Text
State of Residence	Open Text
Zip code	Numeric
Tribal Affiliation	Open Text
Born in the United States	Categorical	Y/N/U/R
Phone Number 1	Numeric
Phone Number 2	Numeric
Email 1	Open Text
Email 2	Open Text
Ok to Text	Categorical	Yes, No, Partial, Refused
Ok to Email	Categorical	Yes, No, Partial, Refused
Race	Categorical	Check all apply	Use Census or HHS categories
Ethnicity	Categorical	Check box	Use Census or HHS categories
Date of interview Attempt 1	Date
Interview 1 occurred	Categorical	Yes, No, Partial, Refused
Date of interview Attempt 2	Date
Interview 2 occurred	Categorical	Yes, No, Partial, Refused
Date of interview Attempt 3	Date
Interview 3 occurred	Categorical	Yes, No, Partial, Refused
Any household contact	Categorical	Y/N/U/R
Total Number of household contacts	Numeric
Can you self-isolate	Categorical	Y/N/U/R	Add in script what this means (use of bedroom and bathroom away from others)
Do you need assistance to self-isolate	Categorical	Y/N/U/R
Symptoms and Clinical Course
Fever	Categorical	Check Box (Y/N/U/R)
Cough	Categorical	Check Box (Y/N/U/R)
Shortness of Breath	Categorical	Check Box (Y/N/U/R)
Diarrhea/GI	Categorical	Check Box (Y/N/U/R)
Headache	Categorical	Check Box (Y/N/U/R)
Muscle ache	Categorical	Check Box (Y/N/U/R)
Chills	Categorical	Check Box (Y/N/U/R)
Sore throat	Categorical	Check Box (Y/N/U/R)
Vomiting	Categorical	Check Box (Y/N/U/R)
Abdominal Pain	Categorical	Check Box (Y/N/U/R)
Nasal congestion	Categorical	Check Box (Y/N/U/R)
Loss of sense of smell	Categorical	Check Box (Y/N/U/R)
Loss of sense of taste	Categorical	Check Box (Y/N/U/R)
Other symptom	Categorical
Other symptom description
Date of symptom onset	Date
SARS-CoV-2 testing	Categorical	Check Box (Y/N/U/R)
Date of first SARS-CoV-2 test	Date
Results of first SARS-CoV-2 test	Categorical	Pos/Neg/Equi/Unk
Date of last SARS-CoV-2 test	Date
Results of last SARS-CoV-2 test	Categorical	Pos/Neg/Equi/Unk
Pre-existing conditions
Chronic lung disease	Categorical	Yes, No, Partial, Refused
Diabetes	Categorical	Yes, No, Partial, Refused
Severe Obesity (BMI>=40)	Categorical	Yes, No, Partial, Refused
CVD	Categorical	Yes, No, Partial, Refused
Chronic renal disease	Categorical	Yes, No, Partial, Refused
Chronic liver disease	Categorical	Yes, No, Partial, Refused
Immunocompromised	Categorical	Yes, No, Partial, Refused
Pregnant (if Female)	Categorical	Yes, No, Partial, Refused
Risk Factors
Contact with confirmed COVID case	Categorical	Y/N/U/R
Employed	Categorical	Yes/No-unemployed/
		No-retired/No-unable to work/No-student
If employed, what occupation	Open text
If employed, what kind of workplace	Open text
HCP	Categorical	Y/N/U/R	Work or volunteer in a healthcare setting
If HCP, what kind of setting
Hospital	Categorical	Check box
Ambulatory care	Categorical	Check box
EMS/Fire/Law Enforcement/1st responder	Categorical	Check box
Urgent care	Categorical	Check box
Long term care	Categorical	Check box
Hospice	Categorical	Check box
Name of HCP setting	Open Text
Address of HCP setting	Open Text
Congregate setting	Categorical	Y/N/U/R	Do you live or work in congregate setting
If Congregate, what kind
Corrections	Categorical	Check box
Dorm	Categorical	Check box
Group home	Categorical	Check box
Multi-family household	Categorical	Check box
Multi-generational household	Categorical	Check box
Name of congregate setting	Open Text
Address of congregate setting	Open Text