Middle East Respiratory Syndrome (Mers) Patient Under Investigation (Pui) Short Form

Middle East Respiratory Syndrome (MERS) Patient Under Investigation (PUI) Short Form

As soon as possible, notify and send completed form to: 1) your local/state health department, and 2) CDC: email (eocreport@cdc.gov, subject line:

MERS Patient Form) or fax (770-488-7107). If you have questions, contact the CDC Emergency Operations Center (EOC) at 770-488-7100.

Today’s Date: ___________________

STATE ID:

___________________

STATE:

__________

COUNTY:

______________________________

Interviewers: Name: _________________________________

Phone:

____________________

Email:

_______________________________

Sex:

M

F Age:

_________

yr

mo Residency:

US resident

non-US resident, country: _________________________________

Date of symptom onset:

_______________________

Symptoms (mark all that apply):

Fever

Chills

Cough

Sore throat

Shortness of breath

Muscle aches

Vomiting

Diarrhea

Other:

__________________________________________________________

0

In the 14 days before symptom onset did the patient (mark all that apply):

Have close contact

1

with a known MERS case?

Have close contact

1

with an ill traveler from the Arabian Peninsula/neighboring country

2

? If Yes, countries:

_______________________________

______________________________________________________________________________________________________________________

Visit or work in a health care facility in the Arabian Peninsula/neighboring country

2

? If Yes, countries:

___________________________________

______________________________________________________________________________________________________________________

2

Travel to/from the Arabian Peninsula/neighboring country

? If Yes, countries:

_______________________________________________________

Date of travel TO this area:

______________________________

Date of travel FROM this area:

____________________________________

Is the patient a member of a severe respiratory illness cluster of unknown etiology?

Yes

No

Unknown

Is the patient a health care worker (HCW)?

Yes

No

Unknown If Yes, did the patient work as a HCW in/near a country in the Arabian

Peninsula

2

in the 14 days before symptom onset?

Yes

No

Unknown If Yes, countries:

___________________________________________

_________________________________________________________________________________________________________________________

Does the patient have any comorbid conditions? (mark all that apply):

None

Unknown

Diabetes

Cardiac disease

Hypertension

Asthma

Chronic pulmonary disease

Immunocompromised

Other: _______________________________________________________

Yes

No

Unknown

Was the patient: Hospitalized? If Yes, admission date: ________________________________

Admitted to the Intensive Care Unit (ICU)?

Intubated?

Did the patient die? If Yes, date of death: _________________________________

Did the patient have clinical or radiologic evidence of pneumonia?

Did the patient have clinical or radiologic evidence of acute respiratory distress syndrome (ARDS)?

General non-MERS-CoV Pathogen Laboratory Testing (mark all that apply)

Pathogen

Pos

Neg

Pending

Not Done

Pathogen

Pos

Neg

Pending

Not Done

Influenza A PCR

Rhinovirus and/or Enterovirus

Influenza B PCR

Coronavirus (not MERS-CoV)

Influenza Rapid Test

Chlamydophila pneumoniae

RSV

Mycoplasma pneumoniae

Human metapneumovirus

Legionella pneumophila

Parainfluenzavirus

Streptococcus pneumoniae

Adenovirus

Other: ____________________

MERS-CoV rRT-PCR Testing (mark all that apply)

Specimen Type

Date Collected

Positive

Negative

Equivocal

Pending

Not Done

Sputum

Bronchoalvelolar lavage (BAL)

Tracheal Aspirate

NP

3

OP

3

NP/OP

3

(circle one)

Serum

Other: ________________________________

For CDC ONLY:

Date Collected

Positive

Negative

Pending

Not Done

MERS-CoV Serology Testing

1

Close contact is defined as: a) being within approximately 6 feet (2 meters) or within the room or care area for a prolonged period of time (e.g., healthcare personnel, household

members) while not wearing recommended personal protective equipment (i.e., gowns, gloves, respirator, eye protection); or b) having direct contact with infectious secretions (e.g.,

being coughed on) while not wearing recommended personal protective equipment. Data to inform the definition of close contact are limited. At this time, brief interactions, such as

walking by a person, are considered low risk and do not constitute close contact.

2

Countries considered in the Arabian Peninsula and neighboring include: Bahrain; Iraq; Iran; Israel, the West Bank and Gaza; Jordan; Kuwait; Lebanon; Oman; Qatar; Saudi Arabia;

Syria; the United Arab Emirates (UAE); and Yemen.

3

Version 6.2, December 2015

NP = nasopharyngeal, OP = oropharyngeal (throat swab)