Philippine Integrated Disease

Surveillance and Response Case Investigation Form
2019 Coronavirus Disease (CoViD-19)
(Annex C)

When are results expected? Disease Reporting Unit/Hospital: Name of Investigator: Date
of Interview,

1. Patient Profile
Last Name First Name Middle Name Birthday Age Sex

Status

The turn around time is about

Occupation Civil Nationality Passport No.

2. Philippine Residence
House No/Lot/Bidg. Street Province

3-4 days.
Municipality/City

SUB-NATIONAL LABORATORY
Region Home Phone No. Cellphone No. Email address

The results of each referring Employer's Name:

3. Overseas Employment Address
Occupation
(for Overseas Filipinoof Work:
Workers)
Place

institution or LGU will be forwarded House No./Bidg. Name Street City/Municipality Province/State
FOR EMERGING AND
to their respective Hospital
Country Office Phone No. Cellphone No.

4. Travel History
RE-EMERGING INFECTIOUS
Epidemiological Surveillance Unit
History of travel/visit/work in other countries Port of exit:
within last 14 days:
( )Yes
( )No

DISEASES
Airline/Sea vessel: Flight/Vessel Date of Departure Date
of Arrival in Philippines:
(HESU) contact person by LCP SNL
Number

5. Exposure History
History of Exposure to Ifyes:

through the following e-mail address:

Known CoViD-19 Case: Date of Contact with Known CoViD-19 Case:

(SNL-EREID)
( )Yes ( )No ( )Unknown

6. Clinical Information

LCPSNLresults@gmail.com Peg
Date of Onset ofIliness.
atTime
inpatient() Outpatient( ) Died( ) Discharged(
Date of Admission/Consultation
) Unknown( )

Fever °C Cough( ) Sore throat( ) Colds ( ) Shortness/difficulty of breathing ( )

Other symptoms, specify

GUIDELINES FOR
Is there any history of other illness? ( )Yes ( )No

For clarifications, please contact the

If YES, specify:
Chest XRAY done? ( )Yes ( )No Are you pregnant?
Ifyes, when? (|
)Yes LMP

LCP SNL-EREID at

( )No

SUBMITTING SPECIMENS
CXR
Results: Other Radiologic Findings:
Pneumonia ( )Yes ( )No (_
) Pending

a
7. Specimen Information

📞 (02) 8924-6101 ext 1034 or 1033 = Virus

FOR
Date received in RITM PCR
Specimen Collected YES, Date Collected Date sent to RITM
i
if
ir
i

(to be filled up by RITM) Result

(| ) Serum

📱 mobile 0966-6337822 or
(__) Oropharyngeal/

SARS-CoV-2
Nasopharyngeal swab
( ) Others
8. Final Classification

0966-6337823

RT-PCR TEST
C Patient Under Investigation (PUI) O Person Under Monitoring (PUM) G Confirmed COViD-19 Case
9. Outcome
Date of Discharge: Condition on Discharge:

( )Died ( )Improved ( )Recovered ( )Transferred ( )Absconded

Name of Informant: (if patient not available) Relationship: Phone No.

* Patient
PLEASE COMPLETE
Investigation
Under THE DATA INSIDE DOTTED BOX
(PUI)
sudden and/or onset of fever (238°C)
the absence cough, and/or sorethroat, and/colds, or diarrhea in
Specimens are accepted
* A person with of other
diagnoses AND
« A person with history of travel from China within 14 days OR
+ A person who visited any health care facility with a known case of CoViD-19

8 am to 8 pm
Person Under Monitoring (PUM)
* An asymptomatic with travel history from China OR
« A person with exposure from a known confirmed CoViD-19 case OR
A person who came from other countries with confirmed CoViD-19 infection EXCEPT China, with no history of exposure, but

MONDAY TO FRIDAY
«
with fever and/or cough

Confirmed Novel Coronavirus Case

with of infection
8 am to 12 noon
« A person laboratory confirmation with 2019 Novel Coronavirus (2019-nCoV)

SATURDAY and SUNDAY

Specimen Drop Off
☎ (02) 8924-6101 ext 1034 or 1033
www.lcp.gov.ph

👍 Facebook: Lung Center of the Philippines

#LabanLung
What are the important information to
consider and check before sending the What is the proper way to handle
1. Place the
specimens? and transport the specimen? NPS/OPS stick
(a &/or b)
1. Freshly obtained swabs are placed in tightly inside the UTM
The complete CoVid test kit includes: tube (d).
capped preferably Sansure sample storage (a) Oropharyngeal swab (OPS) stick
2. Seal the cap
reagent or universal transport media wrapped in of the UTM (d)
(b) Nasopharyngeal swab (NPS) stick
with parafilm/
triple plastic packaging, and transported (c) Tongue depressor
micropore (e)
immediately in a disposable styrofoam box (d) Sansure Storage Reagent (preferably) or

containing adequate ice and ice substitutes to Universal Transport Media (UTM)

maintain a temperature of 2-4°C.

3. Wrap UTM
(labeled with patient’s data)
(d) with a
2. Specimens must not be more than 2 days old from (e) Parafilm/micropore
paper towel or
date of collection. If immediate transport is not (f) Paper towel/gauze
gauze (f).
possible, specimens should be stored at 2-4°C for 4. Place inside
(g) Plastic tube with tight screw cap
plastic tube (g)
a maximum of 2 days.
(labeled with patient’s data)
and firmly
3. The use of reusable plastic cooler boxes for attach screw
(h) Plastic bag with zip-lock (labeled with
cap.
transport is discouraged. The SNL facility does not
assume responsibility for the return of these boxes.
patient’s data)

4. It is mandatory to coordinate with the LCP-SNL at
(02)89246101 local 1034 and the request should
be forwarded 24 hours prior to submission of
sample. Facilities must send the scanned or
screen shot copies of the completed CIF and CF2
a
Forms and LINELIST in Excel Format of the details
on the specimens, including a) Name of Patient,
5. Place inside plastic bag with zip-
lock, properly labeled, and seal
c completely.
b 6. Put in disposable styrofoam box
with adequate ice, cover, seal and
label as follows:

Age, Sex, Birthdate and Residential address b)

h g
From: Sending Hospital
Date of sample collection, and c) Name of d Address
Referring Health Facility/DRU to the following e- Contact number
mail address: LCPSNLsubmit@gmail.com. To: Lung Center of the
Philippines
Please wait for the acknowledgement receipt.
SNL-EREID
5. Submit a complete set of documents, enclosed in a f Quezon Avenue,
separate zip-lock plastic bag and includes e Quezon City
- 2 copies of Case Investigation Form (CIF) 8924-6101 ext 1034
with Disease Reporting Unit/Name of
Investigator 7. Place a BIOHAZARD symbol
- 2 copies of PhilHealth Claim Form 2 signed (download and print) as
by the patient or authorized representative. precautionary measure for transport
- A document containing the following: of infectious material.
• Line list of patient’s names SANSURE sample
• Disease Reporting Unit/ LGU storage reagent
• The institution’s Contact Person,
telephone number and email address d