Talking with the Patient – A Case Investigator’s Guide to COVID-19

Talking with the Patient – A Case Investigator’s Guide to COVID-19
Updated June 7, 2020

Overview

A successful case interview allows for the collection of critical information about a person (patient) diagnosed with COVID-19 and potentially exposed contacts, while providing support, referrals, and answers to questions the patient may have.  The goals of the case interview are to assess the patient’s medical condition, gather information for continued monitoring and support, and obtain the names and location information of their close contacts who may have been exposed to COVID-19. Developing trust and a warm, empathetic rapport while maintaining a professional relationship with the patient is key to providing the most effective support and collecting the most accurate information to inform the next steps in the contact tracing investigation. The interview process should be more than just checking off boxes on a case report form.

Principles for interactions with COVID-19 patients:

  • Ensure and protect confidentiality.
  • Demonstrate ethical and professional conduct.
  • Create a judgement-free zone.
  • Be open-minded (everyone has a unique story).
  • Be attentive and respectful.
  • Be aware of your own biases (cultural humility).
  • Establish open dialogue and pause often to listen.
  • Ask open-ended questions.
  • Use reflective listening techniques.
  • Use culturally and linguistically appropriate language.
  • Employ critical thinking and problem solving.
  • Be flexible with the interview format.
  • Adapt to address concerns and information that naturally arise during conversation.
  • Identify areas of need and link to appropriate resources.
  • Don’t overstep or overpromise.
  • Set the stage for ongoing communication and support during isolation.

Note: Jurisdictions can find additional information by visiting the Principles of Case Investigation and Contact Tracing : Part of a Multipronged Approach to Fight the COVID-19.

Language is important. It sets the stage to build rapport with patients and opens the door to honest dialogue. It is critical to establish open communication with patients diagnosed with COVID-19 so that they feel comfortable disclosing the names and location information of their close contacts. Open communication also helps them express their needs in order to safely self-isolate and helps them feel comfortable seeking help if their COVID-19 symptoms worsen.  If supportive statements and genuine concern are combined with active listening and open-ended questions, powerful information can be gathered to interrupt the spread of the virus. Asking open-ended questions prompts a dialogue and elicits more detailed information; often the information is helpful in learning more about the person and their circumstances. Remember, each person is unique, and this is not intended as a script. The interviewer should carefully listen to responses and add or subtract questions as appropriate.

The intent of this document is to provide suggested communication strategies for COVID-19 case interviews. Scripts may need to be modified to address locality-specific needs, including but not limited to highlighting available resources, cultural nuances, exposure sites, and the capture of epidemiological data. The information below provides suggested language. Appendix A includes a table to assist case investigators in thinking about the various exposure sites where patients may have interacted with close contacts. Interviewers should use what is helpful and the best fit for the interaction; all questions or statements may not be required and additional probing questions may be necessary. Programs are encouraged to share best practices in framing and phrases as they are identified.

Introduction

Aims: Introduce yourself and establish credibility. Verify patient information, build rapport, address confidentiality.

Intro

  • May I speak with [respondent name]?
  • Am I speaking with [respondent name]?
  • Hello, this is [interviewer’s name], from <xxxx health department>, calling for {respondent name]. How are you today?
  • [For minors] Who is your parent/guardian? How can I reach your parent/guardian?
  • What language(s) do you feel most comfortable speaking?
  • I am following up with you to discuss an important health matter. This call is private and intended to assist you with this matter.
  • Is now a good time to talk privately? If not, what time works best for you?
  • If you are not available now, let’s schedule some time to talk about your recent test for COVID-19 /COVID-19 diagnosis. We want to check in on your health and make sure that you can get the referrals and resources you may need, and answer questions that you may have.

Verifying Identity

  • It is important for me to ensure that I am speaking with the right person. What is your full name and date of birth, please?
  • Before we get started, I would like to make sure that the information we received is correct. Please spell your full name. And what name do you go by/what do people call you? What would you like me to call you?

Reason for Call

  • The health department received a report that you may have been tested/diagnosed with COVID-19. We follow up with people with COVID-19 to make sure that they have the information they need to keep themselves and their family safe. We also reach out to their close contacts to notify them of exposure so that they can get tested and quarantine to prevent the spread of COVID-19.
  • I am calling as a follow-up from your recent medical appointment (or test) for COVID-19. I want to check in with you regarding your diagnosis/test result(s) and see how we can support you and stop the spread of the virus.
  • I would like to review some important questions with you so we can provide you with support and work together to stop the spread of COVID-19 in our city/county/town.

Confidentiality and Privacy

  • Before we go into detail, I want to be sure you understand that everything we discuss is confidential. This means that your personal and medical information will be kept private and only shared with those who may need to know, like your health care provider [NOTE: Please consult local data sharing policies between health care providers and health department.]
  • What questions do you have about your privacy/confidentiality?

Other

  • What questions can I answer for you before we start?

Collecting Patient’s Demographic and Locating Information

Aims: Verify patient demographic and locating information; Establish the best way to reach the patient; Obtain information on who resides with patient and emergency and alternate contact numbers.

Intro

  • If it’s OK with you, I’d like to start with a few questions to make sure that the information that we have is correct and also find out the best way to contact you.

Demographic

  • I know that I already confirmed your name. Are there any other names that you go by or that your medical information may be under (e.g., maiden name)?
  • What is your gender?
  • What is your race?
  • What is your ethnicity? Are you of Hispanic origin?
  • Do you have a tribal affiliation? If so, which tribe?
  • [For women] Are you currently pregnant? (If yes) how far along are you (months, weeks)?
  • What is your [any other locally specific socio-demographic information]?

Locating and Contact Information

  • Where do you live (or stay)? What is your address?
  • Where else may have you lived (or stayed) during the past month?
  • [If person indicates that they ‘live on the street’ or are homeless] If you don’t have a regular place that you stay, where is it best to find you? (probe for cross streets, site description, name of building/shelter, where they receive mail, etc.)
  • Who else lives with you? (Who else stays at that address?)
  • How many people regularly stay at that address?
  • What is your cell phone number? Who else might answer that phone?
  • What is the best number for me to reach you? Who else might answer that number?
  • What is the best time to contact you?
  • What is the best number to reach you?
  • What other ways do you like to communicate? (e.g., email, app)

Work

  • What do you do for work (name, location(s), hours)?
  • Where do you work (name, location(s), hours)?
  • Where else do you work (name, location, hours)?
  • What other things do you do to earn money besides the job you just described?
  • When was the last time you were at work?
  • Where you feeling sick when you were there?
  • How does your workplace protect people from COVID-19 (e.g. providing masks for employees, establishing social distancing space with markers for employees/customers, “screening” for temperature and symptoms upon entry, putting up clear plastic dividers between employees or employees and customers, providing hand sanitizer, signs about COVID-19 and how to prevent it, increased cleaning and disinfection)?
  • Some work roles (i.e., health care workers, first responders and critical infrastructure workers) and workplaces such as congregate living settings (e.g., long term nursing facilities, assisted living facilities, group homes, mental health hospitals, correctional facilities, homeless shelters) or workplaces with large work areas (e.g., factories, food processing plants) have special requirements regarding COVID-19. Does your role at your work or work setting fall into any of those categories? If so, we can discuss in more detail about what this means after we talk about your health and what support you may need.

Emergency Contact

  • In case of an emergency, if I could not reach you, who would I call? What is their number? What is that person’s relation to you?

Health Information and Assessing Disease Comprehension

Aims: Disclose positive test result or verify knowledge of COVID-19 diagnosis; Gain insight regarding patient’s knowledge of COVID-19; Provide disease-specific information and guidance for how to manage symptoms; Assess COVID-19 symptoms, onset, and duration in order to develop a baseline for medical monitoring and contact elicitation window; Assess underlying health conditions that patient may have which place them at higher risk for disease complications.

Intro

  • I’d like to talk about your recent test at <testing provider>. Have you heard back about the results?
  • [If patient has NOT been notified of test result] Your test came back positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19). I’d like to talk to you about what this means so that we can work together to keep you as healthy as possible and prevent the spread of the virus. How does that sound?
  • [If patient HAS been notified of test result/diagnosis] I’d like to talk about your positive test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19) OR (your coronavirus disease 2019 (COVID-19) diagnosis—if symptomatic diagnosis without testing) so that we can work together to keep you as healthy as possible and prevent the spread of the virus. How does that sound?
  • There are some things that you can do to manage your symptoms at home. I would like to take a few minutes to talk with you about the virus, find out your symptoms, and discuss how we can support you during this time. I can also answer questions you have about your illness.

Reason for Testing/Health Care Visit

  • Tell me about why you first went to be tested for COVID-19? What were the results? Have you been tested again since that time? What were those the results?
  • Tell me about why you went to [insert specific health care provider] and your diagnosis at your visit?

Disease Comprehension

  • Tell me your understanding of being diagnosed with COVID-19. What does that mean to you?
  • What did your health care provider or the testing center tell you about COVID-19?
  • What have you heard about COVID-19 (e.g., online, in the news, from friends, family, or coworkers)
  • There is a lot of information out there about COVID-19, and sometimes it is hard to know what is fact and what is myth. What questions do you have for me about the virus?
  • Some basic facts about COVID-19 [Note: Recommend both covering this information verbally and providing a handout via email, hardcopy] are:

Symptoms of COVID-19

  • COVID-19 can cause a variety of symptoms. Some COVID-19 symptoms can seem like a common cold and others are more severe and sometimes people have no symptoms. Please let me know if you have had any of the following symptoms and when they started (See Appendix B for a table of COVID-19 symptoms, with space to indicate onset and duration. This Information can help to identify patients who will need to be referred for medical evaluation due to current symptom presentation).
  • What symptoms were you having? When did those symptoms start?
  • [If patient states any of the emergency warning signs (e.g., trouble breathing, persistent pain or pressure in the chest, new confusion, inability to wake or stay awake, or bluish lips or face) refer them for emergency medical attention immediately!]
  • If you call 911 or go to the emergency room, tell them that you have COVID-19 and also wear a cloth face covering when an ambulance comes to get you or if you visit a medical provider.
  • How are you feeling now?

Hospitalization

  • Did your symptoms require you to go to the hospital? Emergency Room? Hospital admission? Intensive Care Unit (ICU)? When? How long were you in the hospital?
  • What other conditions or complications did they identify at the hospital? Please let me know if any of the following apply: flu, bronchitis, pneumonia, acute respiratory distress, low oxygen in the blood, sepsis, stroke, heart attack, kidney failure, etc.
  • Was there a need for you to be on a ventilator during your hospital stay? How long were you on the on a ventilator?
  • How are you feeling since your hospital discharge?
  • Do you have a scheduled follow up with your health care provider? Or are you in communication with them?

Underlying Health Conditions and Other Risk Factors

  • Some other health conditions may affect how COVID-19 affects the body. Sometimes we may need to do extra monitoring for people who have other health conditions to be sure that we can get them help if they need it. Have you ever been diagnosed by your health care provider with any of the following (Please say yes if you have any of the following conditions):
    • Chronic lung disease?
    • Moderate to severe asthma?
    • Heart conditions (list the type of heart condition)?
    • A health condition that affects your immune system? This can be due to any number of things like
      • cancer treatment
      • bone marrow or organ transplantation
      • immune deficiencies
      • HIV or AIDS
      • prolonged use of corticosteroids and other medications that can weaken the immune system
    • Obesity?
    • Diabetes?
    • Chronic kidney disease? If so, are you undergoing dialysis?
    • Chronic liver disease?
    • Other health condition?
  • Some other health conditions may affect how COVID-19 affects the body. Tell me about other health conditions you may have. (If the local health department is collecting data on specific co-morbidities, you may ask about those specific health conditions after asking this question.)
  • What medications do you take for this/these conditions?
  • What medications have you taken recently, either prescribed or over the counter? When did you start them? How long have you taken them?
  • Other activities can increase the risk for complications from COVID-19, including smoking. Do you smoke? When is the last time that you smoked? Vaped?

Other Testing and Medical care

  • Tell me about any other medical care visits you may have had (where, when, why, were you hospitalized? If so, for how long?).
  • What other tests have you had [besides the COVID-19 tests discussed earlier]? Where? When? What were the results?

Other

  • What worries or concerns do you have that you would like to discuss? Who have you told about your COVID-19 diagnosis?
  • What questions do you have for me at this time about COVID-19?

Health Monitoring and Responding to Changes in Health Status

Aims: Cooperatively establish a plan to monitor health status daily; Discuss importance of daily monitoring and develop a clear plan to access medical services should the need arise.

Intro

  • I’d like to talk with you about setting up a plan for you to monitor your health each day so that we can get you help if you need it. Shall we continue?
  • We would like to work with you to set up daily check-ins so that we can make sure that you are okay. This way if your symptoms get worse or you develop new symptoms, we can work together to get you medical care, if you need it.
  • Let’s talk about setting up daily check-ins in order to monitor your health, by taking your temperature every day and keeping track of how you feel.  There are a few things that we can provide to help you monitor your symptoms.

Monitoring Agreements and Tools

  • Some of the more basic items to help you monitor your symptoms and reduce the chance that others in your house get COVID-19 include a washable cloth face covering, gloves, thermometer, 60% alcohol-based hand sanitizer, soap, and EPA-registered household disinfectantexternal icon.
  • We have <name of local monitoring system> set up to help with communication for daily check-ins. Let’s get you registered for that system. We encourage you to register for [email/test messaging/other automated system] which is quick, private, and allows you to provide your information on a schedule that works for you (rather than getting calls from us).
  • What would work best for you? Would you prefer to Facetime, Skype, talk on the phone, text, or email? What time of day is best? How about xx time each day. Would that work for you? What is the best number or email address we can use to communicate with you each day?
  • What do you understand about the monitoring by [mechanism] that you are being asked to do during this time?  What challenges do you foresee with this plan?

Responding If Symptoms Get Worse

  • Sometimes people with COVID-19 can have complications. You will need to be aware of what is happening with your body so that you can tell if you have any emergency warning signs (including trouble breathing, persistent pain or pressure in the chest, new confusion, trouble speaking, trouble swallowing, impaired coordination, inability to wake or stay awake, or bluish lips or face,  or numbness/paralysis on the face/arm/leg). If you have any of these or any other symptoms that are severe or concerning to you, please call your medical provider or go to the emergency room (ER) right away. Don’t wait for your daily check-in.  If you call 911 or go to the emergency room, tell them that you have COVID-19 and also wear a cloth face covering when an ambulance comes to get you or if you visit a medical provider.
  • What is your plan if you develop new symptoms or start to feel sicker?
  • Who do you feel comfortable reaching out to if you feel like your symptoms are getting worse?
  • How would you get to the emergency room if needed?

Medical Provider and Other Support While Sick

  • Where do you usually go when you are sick?
  • Who is your primary medical care provider? What medical appointments/procedures do you have coming up? How comfortable do you feel communicating with them about your symptoms?
  • Who usually helps take care of you when you are sick? Have you told them about your COVID-19 diagnosis?

Other

  • This was a lot of information. What questions did this raise for you about COVID-19?

Reviewing Isolation Recommendations and Resources

Aims: Discuss parameters and importance of isolation recommendations; Assess patient’s concerns and resources to enable safe and healthy isolation; Cooperatively identify potential areas for support and referral.

Intro

  • Now I’d like to talk with you about home isolation, review the recommendations, and identify what you may need to support you and keep you and your family and other household members healthy. How does that sound?
  • Let’s discuss how you can prevent spreading the virus to others. What has your health care provider told you about how you can keep from spreading the virus to your family and other people? What have they told you about home isolation?
  • Since the main way that COVID-19 is spread is through breathing in droplets of the virus through the air, it will be important to keep your family and other household members safe. This will mean that you will have to stay at home, in a separate part of the house from others who live with you, preferably in a bedroom by yourself, and use your own bathroom that no one else uses during this time. Let’s talk about what this looks like for you.
  • Being in isolation means that you will not be able to go to work or the grocery store or other places around town.
  • During self-isolation at home, you will need to limit your interactions with people in your household: stay 6 feet away from them.
  • When interacting with others in your household, you should wear a cloth face covering, over your nose and mouth. Your caregiver may also wear a cloth face covering when caring for you. Children under age 2, or anyone who has trouble breathing, should not wear a mask. Regularly wash your hands and follow other measures outlined in the CDC guidance. [NOTE: case investigator should verbally review updated CDC guidance with the patient during the interview and send information in a link, or handout afterward]
  • If at all possible, stay in your room and have food, other necessities and recreational items left outside the door, to minimize your contact with others. We will talk more in a few minutes about whether you have someone at home who can do these things and if you need more help.
  • COVID-19 can also be transmitted on surfaces. There are a number of things you can do to protect your family and other household members: Like wiping down shared spaces with appropriate cleaning products, keeping a separate set of dishes, silverware and glasses available for your use. I will send you information on how to clean and disinfect your home (for those sharing space with others). It will be important to identify other people who can help you with daily life activities during self-isolation. You will need to stay at home and therefore you will need others to support you with grocery shopping, picking up medications, and caring for children, or family members who you otherwise would be caring for while you are sick.
  • If you have pets, you should remain separate from them during self-isolation, just as you would with other household members, and avoid direct contact, including petting, snuggling, being kissed or licked, sleeping in the same location, and sharing food or bedding. If possible, another person in your household should take care of the pets and should follow standard handwashing practices before and after interacting with the household animal. If you must care for your pet or be around animals while you are sick, wear a cloth face covering and wash your hands before and after you interact with them. [Note: Please share CDC link and any local information regarding management of interactions with pets.]
  • In accordance with the Americans with Disabilities Actexternal icon, service animals are permitted to remain with their handlers.

Assessing Concerns

  • What would home isolation look like for you?
  • What concerns do you have about the situation that I just described?
  • Does this sound like something that would be hard or easy for you? Why? What could you do or what support would you need to address the hardest parts?
  • What would be helpful for you to better understand or remember the instructions about home isolation?

Assessing Living Situation

  • It may be helpful to talk about what kind of support you might need during self-isolation.
  • Let me just doublecheck the address where you are staying. (confirm address).
  • What does your living situation look like? [Probe for type of living environment: single flat, apartment, house, group home, treatment facility, single room only hotel, condo, tent encampment, etc.] How many rooms, bedrooms, bathrooms? Are there shared common areas (e.g., kitchen/dining room/living room/laundry/elevator)?
  • Tell me about the place where you live (prompts: house? Apartment?). Who lives there with you? What are their names/ages? (make a list, see Appendix C)
  • Who else stays there from time to time? When was the last time they were there? What are their names/ages?
  • How many children do you have? What are their ages? Where do they live? When was the last time you saw them?
  • What other children (under 18) are in the home? Who are their parents/guardians?
  • What is your living situation? Who else lives with you? What are their names, ages and relationships to you?
  • Does anyone in your household have other medical conditions, like the ones we reviewed earlier? If so, who and what medical conditions do they have that concern you?
  • Would it be possible for you to have access to your own room and bathroom?
  • How safe do you feel in your current living situation? Have you ever felt threatened, been hit or hurt by someone who you live with? [If patient feels unsafe or answers yes to the second question] We have resources to support you <make domestic violence referral—insert local information>
  • Is there an alternate place that you could stay?
  • Would you consider moving to an offsite location to support you and protect your family/household during your isolation? If this were an option, what would be your concerns?

Assessing Other Supports

  • When you think about what I have just described, what comes to mind? What challenges do you see? What kind of support would you need to overcome them?
  • What challenges do you foresee with maintaining your health and your household during isolation?
  • What do you think will be the hardest thing about isolation? How will you deal with that?
  • Do you have access to fresh water and enough food?
  • How will you prepare your own food? Who can assist you with getting meals?
  • How will you get other household supplies (e.g., toilet paper, soap, etc.)?
  • What medications will you need to take? How long until your prescription needs to be refilled?
  • Who do you provide care for in your household? Children? Parents? Older person? Sick person? Is there someone else who can take on that role?
  • What pets or animals do you have in your household? What kind of supplies will you need for them during your isolation? Is there anyone else who can take care of your pets or animals?
  • Who can assist you with support (e.g., getting meals and other household supplies) during home isolation?
  • What will you do to get food and other essential items without leaving your house?
  • You may be off from work during home isolation or may be able to telework if that is a policy at your workplace and you feel healthy enough to continue working. How will you approach this discussion with your employer? Will you be getting paid sick leave from your employer?
  • What concerns do you have about the financial impact that home isolation will have?
  • What concerns do you have about how home isolation will affect your health and well-being? What do you think you can do or what support do you need to make a positive impact on your health and well-being?
  • How do you think that you staying separate from them will impact your family? How do you think you will deal with that?
  • What assistance would be helpful for you?
  • What would support look like for you during this time?
  • There are support services available to assist you and your family with some of these tasks. Let’s talk about which ones may be helpful to you.
  • What types of medical or other important appointments do you have scheduled over the upcoming weeks? Let’s see how we can work to support you with those appointments.
  • What other supports might you need during your isolation [or period]? [Note: Jurisdictions can adapt the Self-Isolation and Self-Quarantine Home Assessment Checklistpdf icon to evaluate individuals’ ability to safely isolate or quarantine in their homes.]
    • Food
    • Childcare
    • Housing
    • Prescriptions
    • Non-COVID medical care
    • Support with stress, resiliency, mental health
    • Substance use treatment/support groups
    • Translation/interpretation
    • Assistance caring for someone else
    • Transportation
    • Disability accommodations
    • Financial assistance
    • Communication (cell service, internet)
    • Other

Release from Isolation

  • The amount of time that you will be on home isolation depends upon your signs and symptoms and might also depend on test results. [Note: Jurisdictions can find additional information on the discontinuation of self-isolation in CDC’s Contact Tracing Guidance.] Your health care provider will be talking with you to determine when you can be released from home isolation.

Release from Isolation: Special Circumstances

  • In some instances, health care workers and other critical infrastructure workers (without symptoms) have exemptions from the standard isolation procedures, in order to ensure continuity of essential operations. Let’s talk about whether or not this is relevant in your situation [insert locally specific guidance here].

Disclosure Coaching

  • Given that there will need to be a plan for social distancing and also supports set in place to assist you while you are on home isolation, it will be important to think about how to talk about this with those in your household.
  • Who in the household have you told about your COVID-19 diagnosis or test? How did that conversation go?
  • Who in the household are you planning on telling about your COVID-19 diagnosis or test? What do you expect that discussion to look like? [Offer coaching if appropriate] Would you like support in telling them about your diagnosis? Would you like to arrange for a 3-way call, so that I can be available to answer questions that may come up?

Other

  • What other concerns (e.g., someone may be sick, someone may have a pre-existing health condition, kids are little and may be upset to be separated) do you have regarding the home isolation instructions, the members of your household or being separated from them during self-isolation? Let’s discuss some steps to take that may address your concern(s).
  • What questions or concerns do you have about home isolation that we have not covered?

Contact Elicitation

Aims: Discuss parameters and importance of contact elicitation; Assess and allay patient’s concerns; Elicit close contacts who may have been exposed to COVID-19; Identify congregate living and work environments with potential exposure.

Intro

  • Now I would like to discuss your close contacts and identify who may need to be notified of exposure so that they can get tested and quarantine to prevent the spread of COVID-19. How do you feel about that?
  • Many times people continue to live their lives normally when they have a common cold or when they are tired. Some of the early symptoms of COVID-19 can look similar to other illnesses. You may have been out and about not even realizing that you were sick.
  • In order to stop COVID-19 from spreading in the community, we will need to discuss who may have been exposed and work with them to make sure they get care if they need it and have them monitor themsleves for symptoms so that they don’t spread it to others by accident.
  • Not every person you walked by will need to be notified, but those people you spent time talking, working, laughing, crying, or singing with or touching…those people who you were within 6 feet (two meters) for 15 minutes or more, could benefit from checking their symptoms each day so that they can get help early if they start to have symptoms.
  • When we talk about who may have been exposed to COVID-19, you should think about people who live in your household, people at work, and people who you interact with during hobbies, social events, and other daily life activities. You may want to tell some people yourself, and for others the health department can notify them of exposure.
  • It’s important that I emphasize again that your privacy will be protected at all times. The health department will not disclose your name.  We will also not disclose information about the people you have been in contact with. We will simply let them know that they may have been exposed to COVID-19 recently and check-in with them about any symptoms that they may be having and refer them to health care, or else talk to them about how important it is for them quarantine and watch for symptoms so that they don’t spread the virus to others.

Discussing Contact Elicitation Window

  • [For symptomatic patients] Earlier when we talked about your symptoms, you said that <list symptom patient stated came first> was the first symptom that you had from COVID-19. Let me just doublecheck, the date that you first experienced <symptom>. [Note: case investigator should have predetermined the contact elicitation window period based upon clinical information reported by the provider and then confirmed symptom onset with the patient.] We would go back two days before that date, to cover the time frame when you could have passed the virus to someone else, even without symptoms. Since you started isolation on _/__/___, let’s talk about the people you spent time with, the places that you have gone, and other daily life activities between <date> and <date>.
  • [For asymptomatic patients] Since you could have passed the virus to someone else, even without symptoms, we would go back fourteen days before the date of your positive test for COVID-19, to be sure that anyone who may have been exposed has an opportunity to be notified and evaluated. Since you started isolation on _/__/___, let’s talk about the people you spend time with, the places that you have gone, and other daily life activities between <date> and <date>.
  • [Note to case investigator]: For each contact elicited, step through a list of identifying, locating and risk questions. (See Appendices C and D.)

Household Contacts

  • People who live in the same household are more likely to contract COVID-19 because of the close living environment, the amount of time spent together, and the shared surfaces that can transmit the virus. We want to make sure that those who you live with can be tested or evaluated for COVID-19.
  • Now, let’s talk about working together to keep you and your family or other household members healthy.
  • Let’s talk again about the place that you live and the people who stay there with you. (Make and review list, Appendix C ) Previously you talked about, insert the total number of people> who lived there; <insert #> Of adults and <insert #> of children that stay there on a regular basis. Who else stays with you from time to time? Who has stayed there recently?
  • Let’s talk about each of these people (e.g., names, ages, contact information, potential risk for COVID-19 or complications) and then discuss what would be the best way to notify them of exposure. (Appendices C and D.)
  • What other addresses do you use (for mail, or to stay occasionally)? When was the last time that you stayed there? For how long? Who did you spend time with?
  • Who in your household has been sick recently? (If they identify anyone sick, ask what type of symptoms, when started, for how long?)
  • Have they gone to the doctor or to get tested for COVID-19? (If yes, when and where, results?)

Workplace

  • Many people spend a lot of their time at work. Sometimes, people work very close together with the colleagues or customers, travel together for work, or have shared workspaces or commonly shared surfaces that can transmit the virus. Let’s talk about the work that you do and your work environment to see who may need to get tested or evaluated for COVID-19.
  • Earlier we talked about what you do for work. Let me just confirm, I have it listed as [name, location, contact information]. Let’s talk about who from work may need to be evaluated for COVID-19.
  • When was the last time you were at work?
  • What was your last day of work? Did you feel sick on that day?
  • Have you called out sick since then?
  • What have you told them about your diagnosis/test results?
  • What is your work schedule? Do you work full time or part time?
  • Tell me about your work. What do you do there?
  • How do you get to and from work? (Prompts: ride share, employer sponsored bus, carpool, etc.) Who do you travel with?
  • What is your work setting like? (Prompts: is everyone in one room? Do you work in a cubicle? Do you have your own office? How many people are onsite together? Do you have a shared workspace? Do you have a shared breakroom? Do you have an onsite cafeteria? Where do you eat lunch?)
  • (Special Circumstances in the Workplace) Some workplaces have a higher risk for spreading illness if someone is sick with COVID-19. Places where people live together in close contact, known as congregate living environments (hospitals, long-term nursing facilities, assisted living facilities, group homes, mental health hospitals, correctional facilites, homeless shelters) or large factory settings often require an environmental assessment by health specialists in order to make sure that protective measures are put in place, so more peole don’t get sick. Would you describe your workplace as a congregate living or work environment? In what area(s) of the facility do you work? [Note to case investigator: Appendix E is a job aid to assist with a “facility-based” elicitation process].
  • Do you work with the same people all the time or do you often work with different people? What does that look like?
  • Do you provide services in different settings (e.g., airconditioning repair for businesses, physical therapy for nursing homes, carpentry in personal homes)? What locations have you been onsite recently?
  • How often do you have meetings? What meetings have you attended between <date> to <date> and who was there?
  • How often do you travel during the work day? Have you traveled with anyone from work recently? (Probes: For meetings? Supply pickup? Site visits? Vehicle pickup?) If so, who did you travel with, when did you travel, and where did you go?
  • Who at your work has been sick recently?
  • Who else do you know (your family or friends) who works there?

People, Places, Activities and Events

  • Let’s talk about your daily activities from __/__/__ through __/__/__. Let’s talk about people you shared time with, the places you went, and the events you attended. [Note to case investigator: See Appendix A for a list of potential contacts and locations to discuss, and Appendicies C, D and E to assist with information gathering].
  • Why don’t we start with the day before you started self-isolation at home. Where did you go on that day and who did you see?
  • You told me that your first symptom (name of symptom) started on xx/xx/xxx; that looks like a “Monday/Tuesday” around the time you first began to feel ill. Let’s think back to the two days before that. What were you doing then?
  • [If not mentioned as part of the household] Who is your partner/significant other? When did you last see them?
  • What family or friends have you had over recently? Gone to visit recently? Where did you go? Who was there with you?
  • When was the last time that you stood and talked to your neighbors? Or helped each other out with something?
  • Who do you know who also has COVID-19?
  • Has anyone else told you that you may have been exposed to COVID? Who would that be? When did they let you know? Who else do you know who has been sick?
  • If you look through your contacts in your phone, who else comes to mind that may need to be evaluated for COVID-19?
  • Do you have a calendar or other schedule that you use? If you look through your calendar in your phone, what were you doing from <date> to <date>? Who were you with at that time who may need to be evaluated for COVID-19? How did you travel there?
  • Do you use any apps on your phone regularly that may provide clues to your whereabouts? If you look through your phone, at some of those apps (e.g., Facebook, meet up, WhatsApp, Telegram, foursquare, GirlCrew, Instagram, google maps, dating apps, social networking apps), what events did you attend or people did you meet from <date> to <date>?
  • Tell me about your recent activities. When was the last time that you: Got your hair done? Went out to eat or out for drinks? Took a class? Volunteered? Took public transportation? Exercised with others? Celebrated an occasion? Did a group activity? Who else was there? Who may have been sick at the time?
  • Where have you traveled in the last (contact elicitation window period)? Tell me about that trip. Who was with you? Where did you go? How did you travel? Where did you stay and who did you stay with on the trip?

Conclusion

Aims: Check-in on agreements; Answer remaining questions; Set stage for follow-up

Check-in, Questions and Agreements

  • We have talked about a lot of topics today. I want to take a few minutes to check in on how you’re are feeling and discuss our plans.
  • How are you feeling about all of this?
  • What questions do you have for me?
  • How can I (or my agency) be of additional assistance to you?
  • What questions do you have about what will happen next with the information that we have discussed?
  • So, our daily check-ins start tomorrow. What questions do you have about the time and the method that we discussed?
  • And if you start to feel worse your plan was to….?

Acknowledging the difficulty and keeping the door open for contact.

  • I just want to check in to be sure that you know how to reach me if you have other questions or concerns after we get off the phone. My name is spelled, <insert name>, and my phone number is <insert phone number>.
  • Either I or someone from my team may reach out to you to check in to see if you are ok or whether you’ve connected with the other services we talked about today. They will also protect your privacy. We may have other questions that arise. Just wanted to confirm the best number to reach you is <repeat ‘best contact number’ provided by patient>.
  • I can’t thank you enough for talking to me and helping us stop the spread of COVID-19in [location]. I know this is a very difficult time for you and your family, and we truly want everything to go well for you.

Appendix A
This table is intended to assist case investigators in thinking about the various exposure sites where the patient may have interacted with close contacts.

Potential Contacts and Exposure Locations *

Type of Contacts

Locations

Type of Contacts

Household

Locations

Place of residence

Type of Contacts

Family, Friends, and Social Acquaintances 

Locations

Family gatherings, social residential gatherings, exercise/workout settings, hiking or camping, hunting or fishing trips, cooking class, yoga class, dance class, other enrichment classes, book club meeting, birthday party, baby shower, wedding, funeral, barbeque, weekend getaway, block party, holiday pot-luck, vacation, visited family or friends at nursing home/group home, etc.

Type of Contacts

Transportation and Travel

Locations

Lyft, Uber, carpool, bus, commuter van, light rail, train, airline travel, cruise, etc.

Type of Contacts

Community

Locations

Schools, child care, grocery stores, drug stores, shops/shopping malls, restaurants, coffee shops, hardware store, bank, worship centers, movie theaters, sporting events, concerts, bars/brewhouse, night clubs, library, bowling alley, bingo hall, barber shop, hair salon, nail salon, brow or eyelash salon, day spa, tattoo shop, piercing shop, yoga studio, gym, street faire, festival, county/state fair, animal shelter, airport, polling location, etc.

Type of Contacts

Healthcare

Locations

Hospital, emergency room, physician offices, dialysis centers, laboratories, dentist offices, pharmacies, ambulance transport, chiropractor, physical therapy, etc.

Type of Contacts

Congregate Living Settings 

Locations

Medical: hospital (inpatient); acute care facility, skilled nursing facility, long-term medical care facility, etc.

Non-medical: long-term care residential home, assisted living facility, hospice, retirement home, dormitory, group home, correctional facility (prison/jail/juvenile hall), homeless shelter, multigenerational household, renting/sharing dorm rooms and/or beds based on the shift work at factories or food processing plants etc.

*Please note this list is not inclusive of all possible type of contacts or exposure sites.

Covid-19 Symptom Assessment

Appendix B

This table is intended to guide the patient through assessment of COVID-19 symptoms, onset, and duration.  Information gleaned here will inform the contact elicitation window (48 hours prior to start of symptoms until the patient is isolated).

COVID-19 Symptoms

Presence of Symptoms

Date of Onset

Duration

COVID-19 Symptoms

Fever

Presence of Symptoms

Circle (Y/N/U/R)

Date of Onset

Date of onset

Duration

Number of days

COVID-19 Symptoms

Cough

Presence of Symptoms

Circle (Y/N/U/R)

Date of Onset

Date of onset

Duration

Number of days

COVID-19 Symptoms

Diarrhea/GI

Presence of Symptoms

Circle (Y/N/U/R)

Date of Onset

Date of onset

Duration

Number of days

COVID-19 Symptoms

Headache

Presence of Symptoms

Circle (Y/N/U/R)

Date of Onset

Date of onset

Duration

Number of days

COVID-19 Symptoms

Muscle ache

Presence of Symptoms

Circle (Y/N/U/R)

Date of Onset

Date of onset

Duration

Number of days

COVID-19 Symptoms

Chills

Presence of Symptoms

Circle (Y/N/U/R)

Date of Onset

Date of onset

Duration

Number of days

COVID-19 Symptoms

Sore throat

Presence of Symptoms

Circle (Y/N/U/R)

Date of Onset

Date of onset

Duration

Number of days

COVID-19 Symptoms

Vomiting

Presence of Symptoms

Circle (Y/N/U/R)

Date of Onset

Date of onset

Duration

Number of days

COVID-19 Symptoms

Abdominal Pain

Presence of Symptoms

Circle (Y/N/U/R)

Date of Onset

Date of onset

Duration

Number of days

COVID-19 Symptoms

Nasal congestion

Presence of Symptoms

Circle (Y/N/U/R)

Date of Onset

Date of onset

Duration

Number of days

COVID-19 Symptoms

New loss of sense of smell

Presence of Symptoms

Circle (Y/N/U/R)

Date of Onset

Date of onset

Duration

Number of days

COVID-19 Symptoms

New loss of sense of taste

Presence of Symptoms

Circle (Y/N/U/R)

Date of Onset

Date of onset

Duration

Number of days

COVID-19 Symptoms

Malaise

Presence of Symptoms

Circle (Y/N/U/R)

Date of Onset

Date of onset

Duration

Number of days

COVID-19 Symptoms

Fatigue

Presence of Symptoms

Circle (Y/N/U/R)

Date of Onset

Date of onset

Duration

Number of days

COVID-19 Symptoms

Shortness of breath or difficulty/trouble breathing*

Presence of Symptoms

Circle (Y/N/U/R)

Date of Onset

Date of onset

Duration

Number of days

COVID-19 Symptoms

Persistent pain or pressure in the chest*

Presence of Symptoms

Circle (Y/N/U/R)

Date of Onset

Date of onset

Duration

Number of days

COVID-19 Symptoms

New confusion*

Presence of Symptoms

Circle (Y/N/U/R)

Date of Onset

Date of onset

Duration

Number of days

COVID-19 Symptoms

Inability to wake or stay awake*

Presence of Symptoms

Circle (Y/N/U/R)

Date of Onset

Date of onset

Duration

Number of days

COVID-19 Symptoms

Bluish lips or face*

Presence of Symptoms

Circle (Y/N/U/R)

Date of Onset

Date of onset

Duration

Number of days

COVID-19 Symptoms

Other symptom(s)

Presence of Symptoms

Circle (Y/N/U/R)

Date of Onset

Date of onset

Duration

Number of days

*Emergency Warning Signs-Persons with these symptoms should be referred for emergency medical care.

KEY: Y=yes, N=no, U=Unknown, R=refused

Appendix C

This table is intended to assist in elicitation of contact names, locating, risk and other pertinent health information and notification planning. This information will be used to locate and communicate with contacts regarding their exposure, and prioritize follow-up of high-risk individuals and congregate living or work settings.

Contact Elicitation

Appendix C
Name of Contact Relationship to Patient Last Date of Exposure Type/Duration of Exposure (e.g., setting and minutes/hours spent together) Locating Information Risk Information (e.g., HCW, live or work in congregate setting, high-risk individual) Other Pertinent Health Information (Patient Reported)
(e.g., COVID-19 test positive, cough and fever x 3 days)
Initial notification of exposure (e.g. patient, case investigator)
XXX
XXXXXX
wife X/xx/xxx Daily contact, live and sleep together Cell xxxxxx
Address same as patient
Previous surgery and recent completion of chemotherapy for breast cancer No symptoms or tests for COVID-19 patient
XXX
XXXXX
co-worker x/xx/xxx Contact 5 days/week, ride together in truck cab 6-9 hour/day Cell xxxxxx
Address xxxxxxx
Employer xxxxxxx
smoker Increasingly worse cough, stuffy nose, off and on feverish over past week or so Case investigator

(Please note: All of the information contained in this table is “per patient report”. It is recommended that this information be gathered/verified through a direct conversation with the “contact” (the person exposed to COVID-19.))

Appendix D

This table is intended to provide a list of questions to ask the patient about each of their contacts (persons that may have been exposed to COVID-19). This information will be used to locate and communicate with contacts regarding their exposure and to prioritize follow-up of contact at high-risk and contact within congregate living or work settings.

Sample Open Ended Questions for Each Contact Elicited

Sample Open Ended Questions for Each Contact Elicited

What is their name? What name do they go by?

Sample Open Ended Questions for Each Contact Elicited

Who old are they? What is their age, or date of birth?

Sample Open Ended Questions for Each Contact Elicited

What is their gender?

Sample Open Ended Questions for Each Contact Elicited

What is their race/ethnicity?

Sample Open Ended Questions for Each Contact Elicited

What languages do they speak?

Sample Open Ended Questions for Each Contact Elicited

What do they look like (distinguishing features)?

Sample Open Ended Questions for Each Contact Elicited

What is the best way to reach them? Cell number? Email?

Sample Open Ended Questions for Each Contact Elicited

Where do they live? Address? Who do they live with?

Sample Open Ended Questions for Each Contact Elicited

Where do they work, and work location? City, State? What is their job, work function? Works in close proximity with others?

Sample Open Ended Questions for Each Contact Elicited

When did you see them last? When did you last spend time with them? For how long (minutes/hours)?

Sample Open Ended Questions for Each Contact Elicited

What symptoms might they have had?

Sample Open Ended Questions for Each Contact Elicited

Are you aware of any risk factors (like smoking) underlying medical factors (like the ones that we discussed earlier) they may increase their risk for complications from COVID-19? If yes, do you feel comfortable sharing that information? Tell me about them.

Sample Open Ended Questions for Each Contact Elicited

What do they know about your COVID status?

Appendix E

This table is intended to assist in exploring locations or facilities (Exposure Sites)where the patient visited or worked while infectious, identifying specific areas within each facility (Exposure Settings), and people who may have been exposed. This information can be used to inform both facility and individual contact investigations.

Elicitation of Exposure Sites and Settings (Physical Locations)

Appendix E
Exposure Site (facility name and location) Exposure Setting, Area within Facility (e.g., specific room(s), location on production line, room size, description) Type of Exposure (e.g., talking, singing, physical contact) Date(s) of Exposure (most recent date, frequency, other dates in contact elicitation window period) Duration of Time Spent in Setting Contact(s) (e.g., number, category, names) Patient’s Symptoms: Prioritization (Points to Consider: potential infectiousness (symptoms), type of exposure, duration of exposure, proximity)
Group Home
e.g., Visited my son at his group home about a week after my cruise
living room (12 feet x 18 feet) Potluck birthday celebration (singing, laughing, eating, games) Date (one time) 1.5 hours 5 group home residents2 staff day two of symptoms (“extremely tired and icky from travel”)
Son’s bedroom (8 feet x 10 feet) Hugging, Talking, Laughing Date (one time) 2 hours 1 son (group home resident) day two of symptoms (“extremely tired and icky from travel”)
Church
e.g. Sunday service at place of worship
Dressing Room Talking Most recent Date: <Date #1> 30mins
(15 each prior/after)
8 choir members
1 altar assistants (A)
one week into symptoms of hoarse throat, slight cough, fatigue, headache
Talking, singing <Date #2> 30mins (15 each prior/after) 8 choir members (same on both dates)
1 altar assistants (B)
one day prior to symptoms
Choir Seating Section (6 ft x 8 ft) in Chancel Talking, singing Most recent Date: <Date #1> 1 hour service 8 choir members (same as above) one week into symptoms of hoarse throat, slight cough, fatigue, headache
Talking, singing <Date #2> 1 hour service 8 choir members (same as above) one day prior to symptoms
Chancel (containing pulpit, lectern, choir, altar) open structure in church/worship hall (35 ft x 15 ft) Talking, singing <Date #1>
<Date #2>
1 hour service 8 choir members (same as above)
2 pastor(s) (same on both dates)
2 altar assistants (same as above)
one week into symptoms of hoarse throat, slight cough, fatigue, headache and one day prior to symptoms
Nave (congregation seating area) of church/worship hall (separated from Chancel by five steps, open structure, high ceiling, containing rows of seating in pews,.40 feet x 35 feet) Talking, singing <Date #1>
<Date #2>
1 hour service Estimate 42 parishioners one week into symptoms of hoarse throat, slight cough, fatigue, headache and one day prior to symptoms
Meeting Hall (open space 35 feet x 35 feet) for coffee and doughnuts talking <Date #2> 35 minute intense, close conversation 2 council members one day prior to symptoms
talking <Date #2> 1 hour 25 people one day prior to symptoms
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