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Questionnaire form last updated: 2/20/2020

COVID-19 Person Under Monitoring:Questions for Orpheus

View the Oregon Health Authority’s interim investigative guidelines for COVID-19 here.

Summary Case Information

Disease Person Under Monitoring

Risk Level Choose a risk level. Status Under Monitoring

Deceased Choose an item.

Onset Date of PUM case

MM/DD/YYYY Note: This can be entered as the beginning date of the

monitoring period.

PUM Information and Demographics

Full Name First Name Last Name

Date of Birth MM/DD/YYYY

Sex Choose an item.Race and Ethnicity: Choose an item.

Occupation Click or tap here to enter text.

Worksite Click or tap here to enter text.

Phone 1 (###)-###-####. Phone 2 (###)-###-####.

Street Address Line 1 Click or tap here to enter text.

Street Address Line 2 Click or tap here to enter text.

City Click or tap here to enter text.

State AA Zip Code #####

County Choose an item.

PUM Risk Questions

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https://www.oregon.gov/oha/PH/DISEASESCONDITIONS/COMMUNICABLEDISEASE/REPORTINGCOMMUNICABLEDISEASE/REPORTINGGUIDELINES/Documents/Novel-Coronavirus-2019.pdf



Was the PUM interviewed? Choose an item. Interview Date MM/DD/YYYY

Who was interviewed Choose an item.

Interviewed by:

Click or tap here to enter text.

Did the PUM have any travel to mainland China, excluding Hubei Province? Choose an item.

Notes: Include notes and specific travel dates here.

Did the PUM have any travel to Hubei Province, China? Choose an item.

Notes: Include notes and specific travel dates here.

Did the PUM travel with any family members to mainland China? Choose an item.

Notes: Include notes and specific details of other travelers here.

Please make sure that all family members are entered into Orpheus. Sometimes the DGMQ reports are not complete.

Was the PUM an airline contact of a symptomatic, confirmed case while seated OUTSIDE 6 feet of the person? Choose an item.

Notes: Include notes and specific flight details here.

Was the PUM an airline contact of a symptomatic, confirmed case while seated within 6 feet of them? Choose an item.

Notes: Include notes and specific flight details here.

Does the PUM live in the same household as, is an intimate partner of, or provides care in a non-healthcare setting (such as a home) for a symptomatic, confirmed case? Choose an item.

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Notes: Include notes and specific details here.

Does the PUM have close contact to a confirmed, symptomatic case? Choose an item.

Notes: Include notes and specific details here.

PUM Clinical Information: Initial interview

Is the PUM symptomatic? Choose an item.

Date of symptom onset MM/DD/YYYY

Is the PUM a healthcare worker? Choose an item.

Is the PUM hospitalized? Choose an item.

Symptoms

Indicate whether the following symptoms were experienced by this patient:

☐ Fever (>100.4 F) ☐ Coryza ☐ Any cough ☐ Any sore throat

☐ Dyspnea or shortness of breath ☐ Pneumonia diagnosis ☐ ARDS

☐ Mechanical ventilation ☐ Other: Please explain

PUM: Monitoring Information (only if indicated by PUM’s risk level)

First exposure date: MM/DD/YYYY Last exposure date: MM/DD/YYYY

Reason for monitoring: Choose an item.

Choose an item.Monitoring: Day 1

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Date MM/DD/YYYY

Symptoms: ☐ No symptoms ☐ Fever ☐ Cough ☐ Fatigue ☐ Sore Throat

☐ Shortness of breath ☐ Pneumonia ☐ Other: Please explain

Temperature 1 Enter temperature. Temperature 2 Enter temperature.

Monitoring: Day 2

Date MM/DD/YYYY




Monitoring: Day 3

Date MM/DD/YYYY




Monitoring: Day 4

Date MM/DD/YYYY




Monitoring: Day 5

Date MM/DD/YYYY


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Monitoring: Day 6

Date MM/DD/YYYY




Monitoring: Day 7

Date MM/DD/YYYY




Monitoring: Day 8

Date MM/DD/YYYY




Monitoring: Day 9

Date MM/DD/YYYY




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Monitoring: Day 10

Date MM/DD/YYYY




Monitoring: Day 11

Date MM/DD/YYYY




Monitoring: Day 12

Date MM/DD/YYYY




Monitoring: Day 13

Date MM/DD/YYYY




Monitoring: Day 14

Date MM/DD/YYYY

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