Philippine Integrated

Case Investigation Form

Disease Surveillance and
Response Coronavirus Disease (COVID-19)
Version 7.5 (August 18)

PART 1: Patient information

Disease Reporting Unit* DRU Region and Province PhilHealth No.* Date of Interview (MM/DD/YYYY)*

1. Patient Profile
Last Name* Jailani First Name (and Suffix)* Vheji Middle Name* Jumadil
Birthday (MM/DD/YYYY)* March 1, 1990 Age* 30 Sex* / Male □ Female
Civil Status Maried Nationality Filipino Occupation PNP
2. Current Address in the Philippines and Contact Information* (Give address of institution if you live in closed settings, see Part 2 #8)
House No./Lot/Bldg. Street Barangay Municipality/City
135 Putting Lupa San Roque Bulacan
Province Home Phone No. Cellphone No. Email Address
Bulacan 09493542667 09493542667 Salaambulacan@gmail.com
3. Current Workplace Address and Contact Information
House No./Lot/Bldg. Street Barangay Municipality/City
PHQ camp alejo gen santos Brgy. Guinhawa
Province Phone No. Cellphone No. Email Address
Bulacan 0933 5876401 Pcrbulacanppo@gmail.com
4. Consultation and Admission Information
Did you have previous consultation? □ Yes □ No Date of First Consult(MM/DD/YYYY)*
Name of facility where first consult was done
Was the case admitted in a health □ Yes □ No Date of Admission (MM/DD/YYYY)* Indicate earliest date if admitted in multiple
facility? health facilities
Name of Facility where patient was first admitted Region and Province of Facility
5. Disposition at Time of Report* (Provide name of hospital/isolation/quarantine facility)
□ Admitted in hospital □ Admitted in isolation or quarantine facility
□ In home isolation or quarantine □ Discharged to home □ Others
If Discharged: Date of Discharge (MM/DD/YYYY)*
6. Health Status at Consult*
□ Asymptomatic □ Mild □ Moderate □ Severe □ Critical
Date of Onset of Illness (MM/DD/YYYY)* Date of Specimen for PCR testing collected (MM/DD/YYYY)*
7. Classification* (Refer to Appendix 1)
□ Suspect □ Probable □ Confirmed
PART 2: Case Investigation Details
8. Special Population
Health Care Worker* □ Yes / No Returning Overseas Filipino Worker*/ □ Yes □ No
Foreign National Traveler
If Yes, specify name and location of health facility If Yes, indicate country of origin
Locally Stranded Individual* □ Yes □ No Lives in closed settings (e.g. Jails, □ Yes □ No
If Yes, indicate city/mun/prov of origin penitentiaries, mental institutions)* If Yes, specify
9. Permanent Address and Contact Information (If different from current address)
House No./Lot/Bldg. Street Barangay Municipality/City

Province Home Phone No. Cellphone No. Email Address

10. Address Outside the Philippines and Contact Information (for Overseas Filipino Workers and Individuals with Residence outside the Philippines)
House No./Lot/Bldg. Street Municipality/City Province

Country Place of Work Employer’s Name Employer’s/Office Contact No.

11. Clinical Information

Signs and Symptoms (Check all that apply if present) Comorbidities (Check all that apply if present)
□ Fever °C □ Shortness of □ None □ Gastrointestinal
□ Cough breath/Difficulty □ Hypertension □ Genito-urinary
□ Colds breathing □ Diabetes □ Neurological Disease
□ Sore throat □ Others □ Heart Disease □ Cancer
□ Lung Disease □ Others
12. Laboratory Information
Test Done* Date Collected* Laboratory Results* Date Released
□ RT-PCR □ Pending □ Negative
□ Positive □ Equivocal

Instructions: 1) Please fill out all blanks and put a check mark on the appropriate box. Never leave an item blank, just write N/A or not
applicable. Items with * are required fields.
2) All dates must be in MM/DD/YYYY format.
 □ Antigen Test □ Pending □ Negative
□ Positive □ Equivocal
□ Antibody □ IgM (+) IgG (-) □ IgM (+) IgG (+)
Test □ IgG (+) IgM (-) □ IgM (-) IgG (-)
Others: □ Pending □ Negative
□ Positive □ Equivocal
13. Testing Category/Subgroup (Check all that apply) Refer to Appendix 2
□ A □ B □ C □ D □ E □ F □ G □ H □ I □ J
14. Outcome*
□ Active □ Recovered: Date of Recovery (MM/DD/YYYY)
□ Died Cause of Death_ Date of Death (MM/DD/YYYY)*
Part 3: Contact Tracing
15. Exposure History
History of exposure to known confirmed COVID-19 case 14 days before the □ Yes, Date of LAST Contact (MM/DD/YYYY)
onset of signs and symptoms* □ No □ Unknown
Have you been in a place with a known COVID-19 transmission 14 days before □ Yes, Date of Visit (MM/DD/YYYY)
the onset of signs and symptoms?* □ No □ Unknown
If Yes, specify place (Check all that apply and provide details)
□ Unknown exposure □ Home □ Workplace □ Health facility
□ International travel □ Local travel □ Closed settings – jail □ School
□ Social gathering □ Market □ Transportation □ Others
16. Travel History
History of travel/visit/work in other countries with a known COVID-19 □ Yes, Country of exit
transmission 14 days before the onset of signs and symptoms □ No
Airline/Sea vessel Flight/Vessel Number Date of Departure (MM/DD/YYYY) Date of Arrival in PH (MM/DD/YYYY)

History of travel/visit/work in other local place with a known COVID-19 □ Yes, Place of origin
transmission 14 days before the onset of signs and symptoms □ No
Airline/Sea vessel Flight/Vessel Number Date of Departure (MM/DD/YYYY) Date of Arrival in PH (MM/DD/YYYY)

List the names of persons who were with you two days prior to onset of Name Contact No.
illness until this date and their contact numbers (Use additional space below
if needed)
Name of Informant (If patient unavailable) Relationship Contact No.

For Additional Close Contact

Name Contact Number Exposure setting (ex: household, work)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Instructions: 1) Please fill out all blanks and put a check mark on the appropriate box. Never leave an item blank, just write N/A or not
applicable. Items with * are required fields.
2) All dates must be in MM/DD/YYYY format.