TONDO MEDICAL CENTER CIF VERSION 9

1) The Case Investigation Form (CIF) is meant to be administered as an interview by a health care worker or any personnel of the DRU. This is not a self-administered questionnaire.

2) Please be advised that DRUs are only allowed to obtain 1 copy of accomplished CIF from a patient.

3) Please fill out all blanks and put a check mark on the appropriate box. Never leave an item blank (write N/A). Items with * are required fields. All dates must be in MM/DD/YYYY format.
Who will swab?*
Department / Area*
Testing Facility*
Disease Reporting Unit*
DRU Region and Province*
PhilHealth No.
Name of Interviewer*
Contact Number of Interviewer*
Date of Interview

MonthDayYear
Date
Name of Informant (if applicable)*
Relationship*
Contact Number of Informant*
If existing case (check all that apply)*

Not applicable (New case)Not applicable (Unknown)Update symptomsUpdate health statusUpdate outcomeUpdate vaccinationUpdate lab resultUpdate chest imaging findingsUpdate dispositionUpdate exposure/ travel historyOther
Type of Client*

COVID-19 Case (Suspect, Probable, or Confirmed)Close ContactFor RT-PCR Testing (Not a Case of Close Contact)
Testing Category/Subgroup (Check all that apply, refer to Appendix 2)*

A. Individuals with severe/critical symptoms and relevant history of travel and/or contact.B. Individuals with mild symptoms and relevant history of travel/ contact, and considered vulnerable. Vulnerable populations include those elderly and with preexisting medical conditions that predispose them to severe presentation and complications of COVID-19C. Individuals with mild symptoms, and relevant history of travel and/or contactD. Individuals with no symptoms but with relevant history of travel and/or contact or high risk of exposure.E. Frontliners indirectly involved in health care provision in the response againstCOVID-19F. Other vulnerable patients and those living in confined spaces.G. Residents, occupants or workers in a localized area with an active COVID-19 cluster, as identified and declared by the local chief executive in accordance with existing DOH Guidelines and consistent with the National Task Force Memorandum Circular No. 02 s.2020 or the Operational Guidelines on the Application of the Zoning Containment Strategy in the Localization of the National Action Plan AgainstCOVID-19 Response.H. Frontliners in Tourist ZonesI. All workers and employees of manufacturing companies and public service providers registered in economic zones located in Special Concern Areas may be tested regularly.J. Economy Workers
F1 - Pregnant patients who shall be tested during the peripartum period

F2 - Dialysis patients

F3 - Patients who are immunocompromised, such as those who have HIV/AIDS, Inherited diseases that are affect the immune system

F4 - Patients undergoing chemotherapy or radiology

F5 - Patients who will undergo elective surgical procedures with high risk for transmissions

F6 - Any person who have had organ transplants, or have had bone marrow or stem cell transplant in the past 6 months

F7 - Any person who is about to be admitted in enclosed institutions such as jails, penitentiaries, and mental institutions
Please specify classification of "F" category
Tondo Med Employee?*

YesNo
Hospital No*
Vaccination Status*
Classification*
Patient Profile*

First Name (and Suffix)Middle NameLast Name
Birthdate*

MonthDayYear
Date
Today

MonthDayYear
Date
Age - Days
Age*
Sex*

MaleFemale
Civil Status*
Occupation*
Nationality*
Work in a closed setting?

YesNoUnknown
Current Address in the Philippines and Contact Information

(Provide address of institution if patient lives in closed settings)
House No./Lot/Bldg.*
Street/Purok/Sitio*
Barangay*
Municipality/City*
Province*
Home Phone No. (& Area Code)
Cellphone No.*
Email Address*
Same address to current?*

YesNo
Permanent Address and Contact Information

(If different from current address)
House No./Lot/Bldg
Street/Purok/Sitio
Barangay
Municipality
Province
Home Phone No. (& Area Code)
Cellphone No.
Email Address
Current Workplace and Contact Information
Lot/Bldg.*
Street*
Barangay*
Municipality*
Province*
Name of Workplace*
Phone No./ Cellphone No.*
Email Address*
Special population

(indicate further details on exposure and travel history)
Health Care Worker*

YesNo
Name of health facility
Location
Returning Overseas Filipino

YesNo
Country of origin
Passport number
OFW

OFWType option 2
Foreign National Traveler*

YesNo
Country of origin*
Locally Stranded Individual/ APOR/ Local Traveler*

YesNo
City, Municipality, & Province of origin
Locally Stranded IndividualAuthorized Person Outside Residence/ Local Traveler
Lives in Closed Settings*

YesNo
Specify institution type:
e.g prisons, residential facilities retirement communities, care homes, camps, etc
Name of institution
Indigenous Person

YesNo
Consultation Information
Have previous COVID-19 related consultation?*

YesNo
Date

MonthDayYear
Date
Name of facility where first consult was done
Disposition at Time of Report

(Provide name of hospital/isolation/quarantine facility)
Admitted in hospitalAdmitted in isolation/quarantine facilityIn home isolation/quarantineDischarged to homeOther
Name of hospital
Date

MonthDayYear
Date
Time

Hour Minutes

AM/PM Option
Name of isolation/quarantine facility
Date

MonthDayYear
Date
Time

Hour Minutes

AM/PM Option
Date

MonthDayYear
Date
Time

Hour Minutes

AM/PM Option
Date of Discharge

MonthDayYear
Date
Health Status at Consult*

AsymptomaticMildModerateSevereCritical
Case Classification*

SuspectProbableConfirmedNon COVID-19 Case
Received vaccination?*

YesNo
Date of vaccination

MonthDayYear
1st dose
Name of Vaccine
Dose number
e.g 1st, 2nd
Vaccination center/facility
Region of health facility
Adverse event/s?

YesNo
Has received second dose?

YesNo
Date of vaccination

MonthDayYear
1st dose
Name of Vaccine
Dose number
e.g 1st, 2nd
Vaccination center/facility
Region of health facility
Adverse event/s?

YesNo
Has received Booster dose?

YesNo
Date of vaccination

MonthDayYear
1st dose
Name of Vaccine
Booster Dose number
e.g 1st, 2nd
Vaccination center/facility
Region of health facility
Adverse event/s?

YesNo
Has received second booster dose?

YesNo
Date of vaccination

MonthDayYear
1st dose
Name of Vaccine
Booster Dose number
e.g 1st, 2nd
Vaccination center/facility
Region of health facility
Adverse event/s?

YesNo
Clinical Information
Date of Onset of Illness*
MM/DD/YYYY
Signs and Symptoms (Check all that apply)*

AsymptomaticFeverCoughGeneral weaknessFatigueHeadacheMyalgiaSore throatCoryzaDyspneaAnorexiaNauseaVomitingDiarrheaAltered Mental StatusAnosmia (loss of smell, w/o any identified cause)Ageusia (loss of taste, w/o any identified cause)Other
Temperature
Comorbidities (Check all that apply if present)*

NoneHypertensionDiabetesHeart DiseaseLung DiseaseGastrointestinalGenito-urinaryNeurological DiseaseCancerOther
Pregnant?

YesNo
LMP

MonthDayYear
Date
High-risk pregnancy?

YesNo
Was diagnosed to have Severe Acute Respiratory Illness?*

YesNo
Chest imaging findings suggestive of COVID-19
Imaging done*

Chest radiographyChest CTLung ultrasoundNone
Date done

MonthDayYear
Date
Results

NormalPendingChest radiography: Hazy opacities, often rounded in morphology, with peripheral and lower lung dist.Chest CT: Multiple bilateral ground glass opacities, often rounded in morphology, with peripheral and lower lung dist.Lung ultrasound: Thickened pleural lines, B lines, consolidative patterns with or without air bronchogramsOther
Laboratory Information
Have tested positive using RT-PCR before?*

YesNo
Date of specimen collection

MonthDayYear
Date
Laboratory
No. of previous RT-PCR swabs done*
Type of test*

RT-PCR (OPS)RT-PCR (NPS)RT-PCR (OPS and NPS)Antigen test; Provide reason below:Antibody testOther
Date collected

MonthDayYear
Date
Time Collected

Hour Minutes

AM/PM Option
Date released
Laboratory
Results

PendingNegativePositiveEquivocalOther
Outcome/Condition at Time of Report*

Active (currently admitted/isolation/quarantine)RecoveredDied
Date of recovery

MonthDayYear
Date
Date of death

MonthDayYear
Date
Immediate Cause
Antecedent Cause
Underlying Cause
Contributory Conditions
Contact Tracing: Exposure and Travel History
History of exposure to known probable and/or confirmed COVID-19 case 14 days before the onset of signs and symptoms? OR If Asymptomatic, 14 days before swabbing or specimen collection?*

YesNoUnknown
Date of last contact

MonthDayYear
Date
Has the patient been in a place with a known COVID-19 case 14 days before the onset of signs and symptoms? OR If Asymptomatic, 14 days before swabbing or specimen collection?*

Yes, InternationalNoYes, LocalUnknown exposure
Country of origin
From

MonthDayYear
Date
To

MonthDayYear
Date
With ongoing COVID-19 community transmission?

YesNo
Airline/Sea vessel
Flight/Vessel Number
Date of departure

MonthDayYear
Date
Date of arrival in PH

MonthDayYear
Date
-If symptomatic, provide names and contact numbers of persons who were with the patient two days prior to onset of illness until this date

-If Asymptomatic, provide names and contact numbers of persons who were with the patient on the day specimen was submitted for testing until this date.
Name*
Contact Number*
Name*
Contact Number*
Name*
Contact Number*
Name*
Contact Number*
Should be Empty: