WHO SMART Guideline: Surveillance and Outbreak Toolkit
0.2.1 - CI Build International flag

WHO SMART Guideline: Surveillance and Outbreak Toolkit, published by WHO. This is not an authorized publication; it is the continuous build for version 0.2.1. This version is based on the current content of https://github.com/WorldHealthOrganization/smart-ot and changes regularly. See the Directory of published versions

Questionnaire: Generic Respiratory Disease Case Investigation Form

Branch:
LinkIdTextCardinalityTypeDescription & Constraintsdoco
.. Questionnaire-SOTGenericRespiratoryDiseaseCIFGeneric Respiratory Disease Case Investigation FormQuestionnairehttp://worldhealthorganization.github.io/smart-ot/Questionnaire/Questionnaire-SOTGenericRespiratoryDiseaseCIF#0.2.1
... investigationFormGeneric Respiratory Disease Case Investigation Form0..1group
.... basicInformationSection 1: Essential basic Information0..1group
..... dataCollectorInformationA. Data collector Information0..1group
...... nameOfDataCollectorName of data collector0..1string
...... dataCollectorTelephoneNumberData collector telephone number0..1string
...... dataCollectorInstitutionData collector institution0..1string
...... formCompletionDateForm completion date (dd/mm/yyyy)0..1date
..... respondentInformationB. Interview respondent Information (if not patient)0..1group
...... nameOfRespondentName of respondent0..1string
...... respondentTelephoneNumberRespondent telephone number0..1string
...... respondentAddressRespondent address0..1string
...... relationshipToPatientRelationship to patient0..1string
..... signsC. Patient identifier Information0..1group
...... identificationUnique Case ID/cluster number (if applicable)0..1string
...... caseStatusCase Status0..1choiceValue Set: Case Status
...... NameName0..1string
...... countryCountry of residence0..1string
...... SexSex at birth0..1choiceValue Set: SOT Biological Sex
...... BirthDateDate of birth (dd/mm/yyyy)0..1date
...... AgeAge (years,months)0..1string
...... addressAddress (village/town, district, province/region)0..1string
...... telephonePatient telephone number0..1string
.... ClinicalSection 2: Clinical Information0..1group
..... clinicalCourseD. Patient clinical course0..1group
...... symptomsSymptom0..1choiceValue Set: Yes No Unknown
...... symptomOnsetDatedate of onset of symptoms:____/____/______0..1dateEnable When: symptoms = Yes (YesNoUnknown#Yes)
...... presentedToHCFHealth facility visit (including traditional care)0..1choiceValue Set: Yes No Unknown
...... presentedToHCFDateDate of first health facility visit (including traditional care)0..1dateEnable When: presentedToHCF = Yes (YesNoUnknown#Yes)
...... totalHealthFacilitiesVisitedTotal health facilities visited till outcome0..1integer
...... dateOfFirstHospitalizationDate of first hospitalization0..1dateValue Set: Yes No Unknown
...... dateOfICUAdmissionDate of intensive care unit admission0..1dateValue Set: Yes No Unknown
...... startICUStart: ICU0..1date
...... stopICUStop: ICU0..1date
...... dateOfMechanicalVentilationDate of mechanical ventilation0..1dateValue Set: Yes No Unknown
...... startVentilationStart: Mechanical Ventilation0..1date
...... stopVentilationStop: Mechanical Ventilation0..1date
...... dateOfAntiviralTreatmentAntiviral Treatment0..1dateValue Set: Yes No Unknown
...... startVentilationStart: Antiviral Treatment0..1date
...... stopVentilationStop: Antiviral Treatment0..1date
...... outcomeOutcome0..1choiceValue Set: Patient Clinical Course Outcome
...... outcomeDateOutcome date0..1date
..... symptomsE. Patient symptoms (from disease onset) and complications0..1group
...... feverFever (>=38 °C) or history of fever0..1choiceValue Set: Yes No Unknown
...... chillsChills0..1choiceValue Set: Yes No Unknown
...... coughCough0..1choiceValue Set: Yes No Unknown
...... soreThroatSore throat0..1choiceValue Set: Yes No Unknown
...... runnyNoseRunny nose0..1choiceValue Set: Yes No Unknown
...... vomitingVomiting0..1choiceValue Set: Yes No Unknown
...... diarrhoeaDiarrhoea0..1choiceValue Set: Yes No Unknown
...... headacheHeadache0..1choiceValue Set: Yes No Unknown
...... neurologicalSignsNeurological signs0..1choiceValue Set: Yes No Unknown
...... specifyNeurologicalSignsSpecify0..1stringEnable When: neurologicalSigns = Yes (YesNoUnknown#Yes)
...... rashRash0..1choiceValue Set: Yes No Unknown
...... conjunctivitisConjunctivitis0..1choiceValue Set: Yes No Unknown
...... shortnessOfBreathShortness of breath0..1choiceValue Set: Yes No Unknown
...... muscleAchesMuscle aches0..1choiceValue Set: Yes No Unknown
...... pneumoniaByChestXRayPneumonia by chest X-ray0..1choiceValue Set: Yes No Unknown
...... pneumoniaDateStartedDate Started __/__/____0..1dateEnable When: pneumoniaByChestXRay = Yes (YesNoUnknown#Yes)
...... acuteRespiratoryDistressSyndromeAcute respiratory distress syndrome0..1choiceValue Set: Yes No Unknown
...... aRDSDateStartedDate Started __/__/____0..1dateEnable When: acuteRespiratoryDistressSyndrome = Yes (YesNoUnknown#Yes)
...... acuteRenalFailureAcute renal failure0..1choiceValue Set: Yes No Unknown
...... acuteRenalFailureDateStartedDate Started __/__/____0..1dateEnable When: acuteRenalFailure = Yes (YesNoUnknown#Yes)
...... cardiacFailureCardiac failure0..1choiceValue Set: Yes No Unknown
...... cardiacFailureDateStartedDate Started __/__/____0..1dateEnable When: cardiacFailure = Yes (YesNoUnknown#Yes)
...... consumptiveCoagulopathyConsumptive coagulopathy0..1choiceValue Set: Yes No Unknown
...... otherSymptomsOther symptoms (if yes, specify)0..1choiceValue Set: Yes No Unknown
...... otherSymptomsSpecifySpecify0..1stringEnable When: otherSymptoms = Yes (YesNoUnknown#Yes)
..... comorbidityF. Patient pre-existing condition0..1group
...... cancerCancer0..1choiceValue Set: Yes No Unknown
...... diabetesDiabetes0..1choiceValue Set: Yes No Unknown
...... hivImmuneDeficiencyHIV/other immune deficiency0..1choiceValue Set: Yes No Unknown
...... heartDiseaseHeart disease0..1choiceValue Set: Yes No Unknown
...... asthmaAsthma0..1choiceValue Set: Yes No Unknown
...... chronicLungDiseaseChronic lung disease (non-asthma)0..1choiceValue Set: Yes No Unknown
...... chronicLiverDiseaseChronic liver disease0..1choiceValue Set: Yes No Unknown
...... chronicHaematologicalDisorderChronic haematological disorder0..1choiceValue Set: Yes No Unknown
...... pregnancyPregnancy0..1choiceValue Set: Yes No Unknown
...... trimesterIf yes, specify trimester0..1stringValue Set: Yes No Unknown
...... chronicKidneyDiseaseChronic kidney disease0..1choiceValue Set: Yes No Unknown
...... chronicNeurologicalImpairmentChronic neurological impairment0..1choiceValue Set: Yes No Unknown
...... obesityObesity0..1choiceValue Set: Yes No Unknown
...... otherConditionsOther (if yes, specify)0..1stringValue Set: Yes No Unknown
...... influenzaVaccinationPatient was vaccinated for influenza in the past 12 months0..1choiceValue Set: Yes No Unknown
.... ExposureSection 3: Exposure and travel history0..1group
..... comorbidityG. Patient occupational exposures0..1group
...... occupationOccupation (specify location/facility)0..1choiceValue Set: Yes No Unknown
...... healthcareWorkerHealth-care worker (if yes, specify type/location)0..1choiceValue Set: Yes No Unknown
...... laboratoryWorkerLaboratory worker (if yes, specify type/location)0..1choiceValue Set: Yes No Unknown
...... veterinaryWorkerVeterinary worker (if yes, specify animal types handled in the 10 days before illness)0..1choiceValue Set: Yes No Unknown
...... wildlifeWorkerWildlife worker (if yes, specify animal types handled in the 10 days before illness)0..1choiceValue Set: Yes No Unknown
...... liveAnimalMarketWorkerLive animal market worker (if yes, specify animal types handled in the 10 days before illness)0..1choiceValue Set: Yes No Unknown
...... farmWorkerFarm worker (if yes, specify animal types handled in the 10 days before illness)0..1choiceValue Set: Yes No Unknown
..... humanExposureH. Patient human exposures in the 14 days before illness onset0..1group
...... visitedOutpatientFacilityPatient visited outpatient treatment facility (if yes, specify)0..1choiceValue Set: Yes No Unknown
...... visitedTraditionalHealerPatient visited traditional healer (if yes, specify)0..1choiceValue Set: Yes No Unknown
...... visitedInpatientFacilityPatient visited or was admitted to inpatient health facility (if yes, specify)0..1choiceValue Set: Yes No Unknown
...... attendedMassGatheringPatient attended festival or mass gathering (if yes, specify)0..1choiceValue Set: Yes No Unknown
...... exposedToSimilarIllnessPatient exposed to person with similar illness0..1choiceValue Set: Yes No Unknown
...... typeOfContactType of contact0..1choiceValue Set: Contact Type
...... locationOfExposureLocation of exposure0..1choiceValue Set: Exposure Location
...... uniqueCaseIdUnique case ID of sick person (if available)0..1choiceValue Set: Yes No Unknown
...... relationshipToPatientRelationship to current patient (specify, e.g. family, friend, health-care worker, colleague)0..1string
...... bloodLinkedBlood linked (if yes, specify link)0..1choiceValue Set: Yes No Unknown
...... confirmedProbableCaseSick person confirmed or deemed a probable case in current event0..1choiceValue Set: Yes No Unknown
..... travelExposureI. Patient travel history in the 14 days before illness onset (add sheets if multiple locations visited)0..1group
...... travelledOutsidePatient travelled out of first administrative region0..1choiceValue Set: Yes No Unknown
...... travelDetailsspecify location (city or region, country)0..*group
....... destinationDestination0..1string
....... transportTypemodel of Travel0..1string
....... arrivalDateArrival: __/__/__0..1date
....... departureDateDeparture: __/__/__0..1date
...... companionPatient travelled with companions (if yes, specify)0..1choiceValue Set: Yes No Unknown
..... animalExposureJ. Patient animal exposures in the 14 days before illness onset0..1group
...... patientHandledAnimalsPatient handled animals0..1choiceValue Set: Yes No Unknown
...... typesOfAnimalsHandledTypes of animals handled (e.g. pigs, chicken, ducks or others)0..1stringValue Set: Yes No Unknown
...... natureOfContactNature of contact (e.g. feed, groom or slaughter)0..1stringValue Set: Yes No Unknown
...... locationOfAnimalContactLocation of animal contact0..1stringValue Set: Animal Contact Location
...... animalsSickOrDeadWithin 2 weeks before or after contact, any animals sick or dead? (if yes, specify type and number, and proportion from flock or herd)0..1stringValue Set: Yes No Unknown
...... animalsInEnvironmentPatient exposed to animals in environment but did not handle them (e.g. in neighbourhood, farm, zoo, at home, agricultural fair or work)0..1choiceValue Set: Yes No Unknown
...... typesOfAnimalsInEnvironmentTypes of animals in that environment (e.g. pigs, chicken, ducks or others)0..1stringValue Set: Yes No Unknown
...... locationOfExposureToAnimalsLocation of exposure0..1stringValue Set: Animal Exposure Location
...... animalsInEnvironmentSickOrDeadWithin 2 weeks before or after exposure to animals in the environment, any animals sick or dead? (if yes, specify type and number, and proportion from flock or herd)0..1stringValue Set: Yes No Unknown
...... animalByProductsExposurePatient exposed to animal by-products (e.g. bird feathers) or animal excreta (if yes, specify product)0..1stringValue Set: Yes No Unknown
...... visitedLiveAnimalMarketPatient visited live animal market (if yes, specify market)0..1choiceValue Set: Yes No Unknown
...... foodExposureK. Patient food exposures in the 14 days before illness onset0..1group
...... rawConsumptionPatient consumed raw or unpasteurized animal products (if yes, specify products)0..1choiceValue Set: Yes No Unknown
...... rawRemedyConsumptionPatient consumed health or traditional remedies with raw or unpasteurized animal products (if yes, specify products)0..1choiceValue Set: Yes No Unknown
..... perceivedExposureL. Patient perceived exposure0..1group
...... sourceFrom the point of view of the patient or family, what is the likely source of infection and geographic location of exposure?0..1string
.... LaboratorySection 4: Laboratory Information0..1group
..... specimensCollectedSpecimens collected from patient (tick as needed)0..1choiceValue Set: Specimen Collected
..... pathogenTestingDonePathogen testing done (tick as needed)0..1choiceValue Set: Pathogen Tested
..... specimensShippedSpecimens shipped to international reference laboratories0..1choiceValue Set: Yes No Unknown
..... shipmentDateshipment date:0..1date
..... specifySpecimensPositiveSpecify specimen(s) positive0..1string
..... specifyPathogensPositiveSpecify pathogen(s) positive0..1string
..... specifyTargetsPositiveSpecify targets positive (e.g. for MERS-CoV)0..1string
..... specifySubtypePositiveSpecify subtype positive (e.g. for influenza)0..1string
..... specifyTitresSpecify titres (e.g. paired serum for influenza)0..1string

doco Documentation for this format