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Instructions

Thank you for taking the time to complete this form. It is important for us to gather this information to understand the current outbreak and to prevent further illness. Please complete this form for all positive COVID-19 cases, new hospitalizations, and/or deaths. For hospitalizations: only report those admitted as a result of COVID-19 illness, including individuals tested in other healthcare settings.

Additional information not on this form can be entered into the bottom section Notes

For more information or questions about reporting, please contact CaseCoordinationManagement@dhhs.nh.gov, 603-271-4496, or visit: https://www.covid19.nh.gov/resources/general-provider-covid-19-resources-and-information.

Please select type of reporting	Date of Report

General Information

Last Name	First Name	Race	Gender Identity
Date of birth	Sex	Ethnicity	Other Gender
Address
City	County	State	Zip Code
Phone	Alternate Phone	Email

Occupation/Employment (select all that apply)	Other specify:
Employer and/or member of institutional setting?	Please specify other congregate setting

Illness Information

Dates

Symptomatic?	Date of symptom onset

Signs and Symptoms

Please check if patient experienced any of the following signs and symptoms.

Abdominal Pain	Chest Congestion	Chest Pain	Chills
Cough	Diarrhea	Fatigue/Extreme Tiredness	Fever
Headache	Loss of smell	Loss of taste	Muscle Aches
Sinus Congestion	Nausea	Runny Nose	Shortness of Breath
Sore Throat	Vomiting	Other specify:	Other Symptom:

Laboratory Testing

Specify collection Date.	Specimen Source
Please select lab testing type.	If antigen please select type from list	Other antigen type
Test Result.	Laboratory
Last Name Provider Ordering Test	First Name Provider Ordering Test	Provider Facility Name.

Outcome/Hospital Information

Is the patient hospitalized for their illness?	If yes, name of facility where patient received care
Admission Date (if hospitalized)	Discharge Date (if hospitalized)
In ICU?	Required Mechanical Ventilation?
Did the patient die?	Date of Death
Did the provider indicate that COVID-19 was a contributing cause of death?

Vaccination Information

Vaccinated for COVID-19?	Vaccine Type/formulation
Date of 1st vaccine dose	Date of second vaccine dose
Date of additional dose of vaccine if applicable.

Risk Factors/Reason for Testing

(check all that apply within 14 days prior to diagnosis or specimen collection date if asymptomatic)

International/Domestic Travel
Contact to a case
No known risk factors

Please indicate any additional risk information not listed here in the notes section at the bottom of this form.

Health Care Provider

Person Reporting First Name	Person Reporting Last Name	Person Reporting Email.
Physician First name	Physician Last name	Physician Phone Number
Physician Facility/Practice Name	City/Town	State

Additional Notes Section

Please add additional notes or comments here

Department Internal Section Please Skip

Assigned to Investigator