LinkId Text Cardinality Type Description & Constraints Questionnaire-SOTGenericRespiratoryDiseaseCIF Generic Respiratory Disease Case Investigation Form Questionnaire http://worldhealthorganization.github.io/smart-ot/Questionnaire/Questionnaire-SOTGenericRespiratoryDiseaseCIF#0.2.1 investigationForm Generic Respiratory Disease Case Investigation Form 0..1 group basicInformation Section 1: Essential basic Information 0..1 group dataCollectorInformation A. Data collector Information 0..1 group nameOfDataCollector Name of data collector 0..1 string dataCollectorTelephoneNumber Data collector telephone number 0..1 string dataCollectorInstitution Data collector institution 0..1 string formCompletionDate Form completion date (dd/mm/yyyy) 0..1 date respondentInformation B. Interview respondent Information (if not patient) 0..1 group nameOfRespondent Name of respondent 0..1 string respondentTelephoneNumber Respondent telephone number 0..1 string respondentAddress Respondent address 0..1 string relationshipToPatient Relationship to patient 0..1 string signs C. Patient identifier Information 0..1 group identification Unique Case ID/cluster number (if applicable) 0..1 string caseStatus Case Status 0..1 choice Value Set: Case Status Name Name 0..1 string country Country of residence 0..1 string Sex Sex at birth 0..1 choice Value Set: SOT Biological Sex BirthDate Date of birth (dd/mm/yyyy) 0..1 date Age Age (years,months) 0..1 string address Address (village/town, district, province/region) 0..1 string telephone Patient telephone number 0..1 string Clinical Section 2: Clinical Information 0..1 group clinicalCourse D. Patient clinical course 0..1 group symptoms Symptom 0..1 choice Value Set: Yes No Unknown symptomOnsetDate date of onset of symptoms:____/____/______ 0..1 date Enable When: symptoms = Yes (YesNoUnknown#Yes) presentedToHCF Health facility visit (including traditional care) 0..1 choice Value Set: Yes No Unknown presentedToHCFDate Date of first health facility visit (including traditional care) 0..1 date Enable When: presentedToHCF = Yes (YesNoUnknown#Yes) totalHealthFacilitiesVisited Total health facilities visited till outcome 0..1 integer dateOfFirstHospitalization Date of first hospitalization 0..1 date Value Set: Yes No Unknown dateOfICUAdmission Date of intensive care unit admission 0..1 date Value Set: Yes No Unknown startICU Start: ICU 0..1 date stopICU Stop: ICU 0..1 date dateOfMechanicalVentilation Date of mechanical ventilation 0..1 date Value Set: Yes No Unknown startVentilation Start: Mechanical Ventilation 0..1 date stopVentilation Stop: Mechanical Ventilation 0..1 date dateOfAntiviralTreatment Antiviral Treatment 0..1 date Value Set: Yes No Unknown startVentilation Start: Antiviral Treatment 0..1 date stopVentilation Stop: Antiviral Treatment 0..1 date outcome Outcome 0..1 choice Value Set: Patient Clinical Course Outcome outcomeDate Outcome date 0..1 date symptoms E. Patient symptoms (from disease onset) and complications 0..1 group fever Fever (>=38 °C) or history of fever 0..1 choice Value Set: Yes No Unknown chills Chills 0..1 choice Value Set: Yes No Unknown cough Cough 0..1 choice Value Set: Yes No Unknown soreThroat Sore throat 0..1 choice Value Set: Yes No Unknown runnyNose Runny nose 0..1 choice Value Set: Yes No Unknown vomiting Vomiting 0..1 choice Value Set: Yes No Unknown diarrhoea Diarrhoea 0..1 choice Value Set: Yes No Unknown headache Headache 0..1 choice Value Set: Yes No Unknown neurologicalSigns Neurological signs 0..1 choice Value Set: Yes No Unknown specifyNeurologicalSigns Specify 0..1 string Enable When: neurologicalSigns = Yes (YesNoUnknown#Yes) rash Rash 0..1 choice Value Set: Yes No Unknown conjunctivitis Conjunctivitis 0..1 choice Value Set: Yes No Unknown shortnessOfBreath Shortness of breath 0..1 choice Value Set: Yes No Unknown muscleAches Muscle aches 0..1 choice Value Set: Yes No Unknown pneumoniaByChestXRay Pneumonia by chest X-ray 0..1 choice Value Set: Yes No Unknown pneumoniaDateStarted Date Started __/__/____ 0..1 date Enable When: pneumoniaByChestXRay = Yes (YesNoUnknown#Yes) acuteRespiratoryDistressSyndrome Acute respiratory distress syndrome 0..1 choice Value Set: Yes No Unknown aRDSDateStarted Date Started __/__/____ 0..1 date Enable When: acuteRespiratoryDistressSyndrome = Yes (YesNoUnknown#Yes) acuteRenalFailure Acute renal failure 0..1 choice Value Set: Yes No Unknown acuteRenalFailureDateStarted Date Started __/__/____ 0..1 date Enable When: acuteRenalFailure = Yes (YesNoUnknown#Yes) cardiacFailure Cardiac failure 0..1 choice Value Set: Yes No Unknown cardiacFailureDateStarted Date Started __/__/____ 0..1 date Enable When: cardiacFailure = Yes (YesNoUnknown#Yes) consumptiveCoagulopathy Consumptive coagulopathy 0..1 choice Value Set: Yes No Unknown otherSymptoms Other symptoms (if yes, specify) 0..1 choice Value Set: Yes No Unknown otherSymptomsSpecify Specify 0..1 string Enable When: otherSymptoms = Yes (YesNoUnknown#Yes) comorbidity F. Patient pre-existing condition 0..1 group cancer Cancer 0..1 choice Value Set: Yes No Unknown diabetes Diabetes 0..1 choice Value Set: Yes No Unknown hivImmuneDeficiency HIV/other immune deficiency 0..1 choice Value Set: Yes No Unknown heartDisease Heart disease 0..1 choice Value Set: Yes No Unknown asthma Asthma 0..1 choice Value Set: Yes No Unknown chronicLungDisease Chronic lung disease (non-asthma) 0..1 choice Value Set: Yes No Unknown chronicLiverDisease Chronic liver disease 0..1 choice Value Set: Yes No Unknown chronicHaematologicalDisorder Chronic haematological disorder 0..1 choice Value Set: Yes No Unknown pregnancy Pregnancy 0..1 choice Value Set: Yes No Unknown trimester If yes, specify trimester 0..1 string Value Set: Yes No Unknown chronicKidneyDisease Chronic kidney disease 0..1 choice Value Set: Yes No Unknown chronicNeurologicalImpairment Chronic neurological impairment 0..1 choice Value Set: Yes No Unknown obesity Obesity 0..1 choice Value Set: Yes No Unknown otherConditions Other (if yes, specify) 0..1 string Value Set: Yes No Unknown influenzaVaccination Patient was vaccinated for influenza in the past 12 months 0..1 choice Value Set: Yes No Unknown Exposure Section 3: Exposure and travel history 0..1 group comorbidity G. Patient occupational exposures 0..1 group occupation Occupation (specify location/facility) 0..1 choice Value Set: Yes No Unknown healthcareWorker Health-care worker (if yes, specify type/location) 0..1 choice Value Set: Yes No Unknown laboratoryWorker Laboratory worker (if yes, specify type/location) 0..1 choice Value Set: Yes No Unknown veterinaryWorker Veterinary worker (if yes, specify animal types handled in the 10 days before illness) 0..1 choice Value Set: Yes No Unknown wildlifeWorker Wildlife worker (if yes, specify animal types handled in the 10 days before illness) 0..1 choice Value Set: Yes No Unknown liveAnimalMarketWorker Live animal market worker (if yes, specify animal types handled in the 10 days before illness) 0..1 choice Value Set: Yes No Unknown farmWorker Farm worker (if yes, specify animal types handled in the 10 days before illness) 0..1 choice Value Set: Yes No Unknown humanExposure H. Patient human exposures in the 14 days before illness onset 0..1 group visitedOutpatientFacility Patient visited outpatient treatment facility (if yes, specify) 0..1 choice Value Set: Yes No Unknown visitedTraditionalHealer Patient visited traditional healer (if yes, specify) 0..1 choice Value Set: Yes No Unknown visitedInpatientFacility Patient visited or was admitted to inpatient health facility (if yes, specify) 0..1 choice Value Set: Yes No Unknown attendedMassGathering Patient attended festival or mass gathering (if yes, specify) 0..1 choice Value Set: Yes No Unknown exposedToSimilarIllness Patient exposed to person with similar illness 0..1 choice Value Set: Yes No Unknown typeOfContact Type of contact 0..1 choice Value Set: Contact Type locationOfExposure Location of exposure 0..1 choice Value Set: Exposure Location uniqueCaseId Unique case ID of sick person (if available) 0..1 choice Value Set: Yes No Unknown relationshipToPatient Relationship to current patient (specify, e.g. family, friend, health-care worker, colleague) 0..1 string bloodLinked Blood linked (if yes, specify link) 0..1 choice Value Set: Yes No Unknown confirmedProbableCase Sick person confirmed or deemed a probable case in current event 0..1 choice Value Set: Yes No Unknown travelExposure I. Patient travel history in the 14 days before illness onset (add sheets if multiple locations visited) 0..1 group travelledOutside Patient travelled out of first administrative region 0..1 choice Value Set: Yes No Unknown travelDetails specify location (city or region, country) 0..* group destination Destination 0..1 string transportType model of Travel 0..1 string arrivalDate Arrival: __/__/__ 0..1 date departureDate Departure: __/__/__ 0..1 date companion Patient travelled with companions (if yes, specify) 0..1 choice Value Set: Yes No Unknown animalExposure J. Patient animal exposures in the 14 days before illness onset 0..1 group patientHandledAnimals Patient handled animals 0..1 choice Value Set: Yes No Unknown typesOfAnimalsHandled Types of animals handled (e.g. pigs, chicken, ducks or others) 0..1 string Value Set: Yes No Unknown natureOfContact Nature of contact (e.g. feed, groom or slaughter) 0..1 string Value Set: Yes No Unknown locationOfAnimalContact Location of animal contact 0..1 string Value Set: Animal Contact Location animalsSickOrDead Within 2 weeks before or after contact, any animals sick or dead? (if yes, specify type and number, and proportion from flock or herd) 0..1 string Value Set: Yes No Unknown animalsInEnvironment Patient exposed to animals in environment but did not handle them (e.g. in neighbourhood, farm, zoo, at home, agricultural fair or work) 0..1 choice Value Set: Yes No Unknown typesOfAnimalsInEnvironment Types of animals in that environment (e.g. pigs, chicken, ducks or others) 0..1 string Value Set: Yes No Unknown locationOfExposureToAnimals Location of exposure 0..1 string Value Set: Animal Exposure Location animalsInEnvironmentSickOrDead Within 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..1 string Value Set: Yes No Unknown animalByProductsExposure Patient exposed to animal by-products (e.g. bird feathers) or animal excreta (if yes, specify product) 0..1 string Value Set: Yes No Unknown visitedLiveAnimalMarket Patient visited live animal market (if yes, specify market) 0..1 choice Value Set: Yes No Unknown foodExposure K. Patient food exposures in the 14 days before illness onset 0..1 group rawConsumption Patient consumed raw or unpasteurized animal products (if yes, specify products) 0..1 choice Value Set: Yes No Unknown rawRemedyConsumption Patient consumed health or traditional remedies with raw or unpasteurized animal products (if yes, specify products) 0..1 choice Value Set: Yes No Unknown perceivedExposure L. Patient perceived exposure 0..1 group source From the point of view of the patient or family, what is the likely source of infection and geographic location of exposure? 0..1 string Laboratory Section 4: Laboratory Information 0..1 group specimensCollected Specimens collected from patient (tick as needed) 0..1 choice Value Set: Specimen Collected pathogenTestingDone Pathogen testing done (tick as needed) 0..1 choice Value Set: Pathogen Tested specimensShipped Specimens shipped to international reference laboratories 0..1 choice Value Set: Yes No Unknown shipmentDate shipment date: 0..1 date specifySpecimensPositive Specify specimen(s) positive 0..1 string specifyPathogensPositive Specify pathogen(s) positive 0..1 string specifyTargetsPositive Specify targets positive (e.g. for MERS-CoV) 0..1 string specifySubtypePositive Specify subtype positive (e.g. for influenza) 0..1 string specifyTitres Specify titres (e.g. paired serum for influenza) 0..1 string Documentation for this format
Generic Respiratory Disease Case Investigation Form
B. Interview respondent Information (if not patient)
Unique Case ID/cluster number (if applicable)
Address (village/town, district, province/region)
date of onset of symptoms:____/____/______
Health facility visit (including traditional care)
Date of first health facility visit (including traditional care)
Total health facilities visited till outcome
E. Patient symptoms (from disease onset) and complications
Patient was vaccinated for influenza in the past 12 months
Health-care worker (if yes, specify type/location)
Laboratory worker (if yes, specify type/location)
Veterinary worker (if yes, specify animal types handled in the 10 days before illness)
Wildlife worker (if yes, specify animal types handled in the 10 days before illness)
Live animal market worker (if yes, specify animal types handled in the 10 days before illness)
Farm worker (if yes, specify animal types handled in the 10 days before illness)
H. Patient human exposures in the 14 days before illness onset
Patient visited outpatient treatment facility (if yes, specify)
Patient visited traditional healer (if yes, specify)
Patient visited or was admitted to inpatient health facility (if yes, specify)
Patient attended festival or mass gathering (if yes, specify)
Patient exposed to person with similar illness
Unique case ID of sick person (if available)
Relationship to current patient (specify, e.g. family, friend, health-care worker, colleague)
Sick person confirmed or deemed a probable case in current event
I. Patient travel history in the 14 days before illness onset (add sheets if multiple locations visited)
Patient travelled out of first administrative region
specify location (city or region, country)
Patient travelled with companions (if yes, specify)
J. Patient animal exposures in the 14 days before illness onset
Types of animals handled (e.g. pigs, chicken, ducks or others)
Nature of contact (e.g. feed, groom or slaughter)
Within 2 weeks before or after contact, any animals sick or dead? (if yes, specify type and number, and proportion from flock or herd)
Patient exposed to animals in environment but did not handle them (e.g. in neighbourhood, farm, zoo, at home, agricultural fair or work)
Types of animals in that environment (e.g. pigs, chicken, ducks or others)
Within 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)
Patient exposed to animal by-products (e.g. bird feathers) or animal excreta (if yes, specify product)
Patient visited live animal market (if yes, specify market)
K. Patient food exposures in the 14 days before illness onset
Patient consumed raw or unpasteurized animal products (if yes, specify products)
Patient consumed health or traditional remedies with raw or unpasteurized animal products (if yes, specify products)
From the point of view of the patient or family, what is the likely source of infection and geographic location of exposure?
Specimens collected from patient (tick as needed)
Specimens shipped to international reference laboratories
Specify targets positive (e.g. for MERS-CoV)
Specify subtype positive (e.g. for influenza)
Specify titres (e.g. paired serum for influenza)