Case Investigation Form (CIFv9)

Email *

Data Privacy Notice:

All Personal Data collected by MMMC using this online form shall be used for the purpose of COVID 19 prevention and control. The Data Subject are fully aware that all information gathered from them are stored in a secured storage system/area within the premise of the hospital which can be accessed only by those authorized staff to guarantee its integrity and confidentiality. No Personal Data shall be disclosed to Third Party without prior permission from the Data Subject and to ensure its Availability, MMMC shall retain it in accordance to its Document Retention Period.

I confirm that I have read, understood and agree with the Data Privacy Notice *

Authorization to gather specimen:

I hereby authorize the performance by MMMC HCW upon myself, nasopharyngeal and oropharyngeal swabs to gather specimen for PCR Testing and Genome Testing (if fit with the criteria) and filling out the Case Investigation Form. I certify that i have fully understood the explanations referred to therein have been made.

Yes *

Information Source

I am filing for/as the *

Part 1. Patient Information

PhilHealth No.*

First Name *

Last Name *

Middle Name *

Birthday (mm/dd/yyyy) *

Age*

Sex:*

Civil Status:*

Nationality:*

Works in a closed settings?*
(ex. Prison , Residential facilities , Retirement communities , Care homes , Camps)

Current Address in the Philippines and Contact Information*

House No./Lot/:*
(Please provide nearest landmark)

Street/Purok/Sitio:*

Barangay:*

Municipality/City:*

Province:*

Home Phone No.:

Cellphone No.:*

Email Address:*

Address Question

Is your current address your Permanent Address*

Permanent Address and Contact Information

House No./Lot:
(Please provide nearest landmark)

Street/Purok/Sitio:

Barangay:*

Municipality/City:*

Province:*

Home Phone No.:

Cellphone No.:*

Email Address:

Occupation

Are you currently employed?*

Occupation*

Current Workplace Address and Contact Information

House No./Lot:
(Please provide nearest landmark

Street/Purok/Sitio:

Barangay:

Municipality/City:

Province:

Home Phone No.:

Cellphone No.:

Email Address:

Special Population

(indicate further details on exposure and travel history in Part 3)

Health Care Worker Question

Are you a Health Care Worker?*

Name of the health facility*

Location of the health facility*

Returning Overseas Filipino Question

Are you a returning Overseas Filipino*

Country of origin*

Passport number*

Are you an OFW?*

Foreign National Traveler Question

Are you a Foreign National Traveler*

Country of origin*

Passport number*

Locally Stranded Individual / APOR / Local Traveler Question

Are you a Locally Stranded Individual / APOR / Local Traveler*

City*

Municipality*

Province*

Lives in Closed Settings Question

Do you live in a Closed Settings*

Specify the institution type*

Prisons

Residential facilities

Retirement communities

Care homes

Camps

Other

Name of the Institution:*

Part 2. Case Investigation Details

Consultation Information Question

Did you have a previous COVID-19 related consultation?*

Previous Consultation

Date of First Consult:*

Name of facility where first consult was done*

Disposition at Time of Report

Name of the Hospital/Isolation/Quarantine Facility

Date and Time admitted/home isolation/quarantine

Where you admitted/home isolation/quarantine?

Date of Discharged

Others

Health Status at Consult ( Please Refer to Appendix 3 )

What is your health status?*

Case Classification ( Please Refer to Appendix 1 )

Case Classification*

Vaccination Question

Did you received any COVID-19 vaccine in the past?*

Vaccination Information 1 ( 1ST DOSE )

Date of first vaccination*

Name of Vaccine*

Dose number*

Vaccination center/facility*

Region of facility*

Adverse event/s?*

Vaccination Information 2 ( 2ND DOSE )

Date of second vaccination

Name of Vaccine

Dose number

Vaccination center/facility

Region of facility

Adverse event/s?

Comorbidity

With Comorbidity?*

Comorbidities*

Hypertension

Diabetes

Heart Disease

Gastrointestinal

Genito-urinary

Neurological Disease

Cancer

Other

Pregnancy and Respiratory

Are you pregnant?*

Last Menstruation Period (LMP)

High-risk pregnancy?

Were you diagnosed to have Severe Acute Respiratory Illness?* ( Please Refer to Appendix 1 )

Laboratory Information Question

Have you been tested positive using RT-PCR before*

Test Result 1 & 2

Test Results 1

Preferred date of collection *

Type of test*

Purpose*

Test Results 2

Preferred date of collection collection

Type of test

Purpose

Outcome/Condition at Time of Report

Outcome/Condition at Time of Report*

If DIED

If DIED, date of death

Immediate Cause:

Antecedent Cause:

Underlying Cause

Contributory Conditions:

Part 3. 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?*

Date of last Contact

Travel Question

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

International Travel, country of origin

Country of origin*

Travel Date From*

To*

Is the country of origin with an ongoing COVID-19 community transmission*

Airline/Sea vessel*

Flight/Vessel Number*

Date of departure*

Date of arrival in PH*

Local Travel

Travel List

Location Name

Location Address

Date Travel From

Is the country of origin with an ongoing COVID-19 community transmission

Persons who were with you

List the names of persons who were with you two days prior to onset of illness until this date and their contact numbers. - 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

1. Name of Person

Contact Number

2. Name of Person

Contact Number

3. Name of Person

Contact Number

Isolation Precaution:

I HEREBY AGREE TO FOLLOW STRICT ISOLATION PRECAUTION UNTIL I RECEIVE THE OFFICIAL RESULT OF MY RT PCR TEST.

Yes *

Authorization to send result to email:

I HEREBY AUTHORIZE MMMC MEDICAL RECORDS SECTION TO SEND THE OFFICIAL COPY OF MY RT PCR TEST RESULT TO THE EMAIL ADDRESS I’VE PROVIDED WITHIN 24 - 48HRS. FOR CORPORATE ACCOUNTS I UNDERSTAND THAT MY RESULT WILL BE FORWARDED DIRECTLY TO MY COMPANY

Yes *

Certification of information:

I HEREBY CERTIFY THAT THE INFORMATION SUBMITTED IN THIS APPLICATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I FURTHER UNDERSTAND THAT ANY FALSE STATEMENTS MAY RESULT IN POSSIBLE LEGAL IMPLICATIONS AS FAR AS NATIONAL HEALTH WELFARE IS CONCERNED.

Yes *