Date of Survey Entry
* must provide value
Today M-D-Y
Reporter Name
* must provide value
Reporter Role/Speciality
* must provide value
Infectious Disease Provider
Primary Care Provider
Hospitalist
Nurse
Administrator
Other
Infectious Disease Provider
Primary Care Provider
Hospitalist
Nurse
Administrator
Other
If other, please list
* must provide value
Reporter State
* must provide value
AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY AE AP AA
Patient Age
* must provide value
Must be 18-89 years old
Gender (genetic)
* must provide value
male
female
other
Race (may check more than one)
* must provide value
Ethnicity
* must provide value
Hispanic / Latino
Not Hispanic / Latino
Unknown / Not available
Hispanic / Latino
Not Hispanic / Latino
Unknown / Not available
Smoking Status
* must provide value
Current smoker
Former smoker
Never smoker
Unknown
Current smoker
Former smoker
Never smoker
Unknown
Vaping Status
* must provide value
Currently Vapes
Former Vape
Never Vaped
Unknown
Currently Vapes
Former Vape
Never Vaped
Unknown
Drug Abuse Status (excluding marijuana)
* must provide value
Current regular abuse
Infrequent abuse
Past abuse
Never use
Unknown
Current regular abuse
Infrequent abuse
Past abuse
Never use
Unknown
When was Initial HIV Diagnosis?
* must provide value
Concurrent with COVID-19
Less than One Year
1-5 Years
More than 5 Years
Unknown
Concurrent with COVID-19
Less than One Year
1-5 Years
More than 5 Years
Unknown
Is CD4 Count Available Pre-COVID or During COVID Infection?
(Pre-COVID Preferred and you will be prompted for value)
* must provide value
Pre-COVID During COVID Not Available
Please enter CD4 from timeframe indication in previous question (cells/mm3)
Is HIV Viral Load Available Pre-COVID or During COVID Infection?
(Pre-COVID preferred and you will be prompted for value)
* must provide value
Pre-COVID During COVID Not Available
Please enter HIV VL from timeframe indication in previous question (copies/mL)
Pre-COVID-19 AIDS characterization (Ever had an AIDS defining illness or CD4< 200 at any time)
* must provide value
AIDS
Never met AIDS criteria
Not Known
AIDS
Never met AIDS criteria
Not Known
Bictegravir/tenofovir alfenamide/emtricitabine
Dolutegravir/abacavir/lamivudine
Dolutegravir/tenofovir alfenamide/emtricitabine
Dolutegravir/tenofovir fumarate/emtricitabine (or 3TC)
Darunavir/cobicistat/tenofovir alfenamide/emtricitabine
Darunavir/ritonavir/tenofovir alfenamide/emtricitabine
Darunavir/ritonavir/tenofovir fumarate/emtricitabine (or 3TC)
Efavirenz/tenofovir fumarate/emtricitabine (Atripla)
Elvitegravir/cobicistat/tenofovir alfenamide/emtricitabine (Genvoya)
Raltegravir/tenofovir alfenamide/emtricitabine
Raltegravir/tenofovir fumarate/emtricitabine (or 3TC)
Rilpivirine/tenofovir alfenamide/emtricitabine
Other
Bictegravir/tenofovir alfenamide/emtricitabine
Dolutegravir/abacavir/lamivudine
Dolutegravir/tenofovir alfenamide/emtricitabine
Dolutegravir/tenofovir fumarate/emtricitabine (or 3TC)
Darunavir/cobicistat/tenofovir alfenamide/emtricitabine
Darunavir/ritonavir/tenofovir alfenamide/emtricitabine
Darunavir/ritonavir/tenofovir fumarate/emtricitabine (or 3TC)
Efavirenz/tenofovir fumarate/emtricitabine (Atripla)
Elvitegravir/cobicistat/tenofovir alfenamide/emtricitabine (Genvoya)
Raltegravir/tenofovir alfenamide/emtricitabine
Raltegravir/tenofovir fumarate/emtricitabine (or 3TC)
Rilpivirine/tenofovir alfenamide/emtricitabine
Other
If other ARV regimen- please specify regimen
Was the patient taking any of the following? (select all that apply)
Was ACE inhibitor continued?
Yes
No
Yes
No
Were glucocorticoids continued?
Yes
No
Yes
No
Was PD5 inhibitor continued?
Yes
No
Were immune modulators continued?
Yes
No
Were biologics continued?
Yes
No
Check all Comorbidities Patient has Prior to COVID-19 Diagnosis
* must provide value
Does patient have any concurrent AIDS defining illnesses?
* must provide value
Bacterial infections multiple or recurrent
Candidiasis of bronchi trachea or lungs
Candidiasis of the esophagus
Cervical cancer (invasive)
Coccidioidomycosis disseminated
Cryptococcosis presenting outside of the lung
Cryptosporidiosis intestinal > 1month
Cytomegalovirus (CMV) with loss of vision
Cytomegalovirus disease (other than liver, spleen, or lymph nodes)
Encephalopathy (HIV-related)
Herpes simplex virus (HSV> 1month or other than the skin)
Histoplasmosis, disseminated
Kaposi's sarcoma (KS)
Lymphoid interstitial pneumonia or lymphoid hyperplasia complex
Burkitt lymphoma
Immunoblastic lymphoma
Primary lymphoma of the brain
Mycobacterium avium complex or Mycobacterium kansasii, disseminated
Mycobacterium tuberculosis of any site in or out of the lungs
Mycobacterium or similar species disseminated beyond the lung
Pneumocystis pneumonia
Pneumonia recurrent
Progressive multifocal leukoencephalopathy (PML)
Salmonella septicemia, recurrent
Toxoplasmosis of the brain
Tuberculosis
Wasting syndrome
None Bacterial infections multiple or recurrent
Candidiasis of bronchi trachea or lungs
Candidiasis of the esophagus
Cervical cancer (invasive)
Coccidioidomycosis disseminated
Cryptococcosis presenting outside of the lung
Cryptosporidiosis intestinal > 1month
Cytomegalovirus (CMV) with loss of vision
Cytomegalovirus disease (other than liver, spleen, or lymph nodes)
Encephalopathy (HIV-related)
Herpes simplex virus (HSV> 1month or other than the skin)
Histoplasmosis, disseminated
Kaposi's sarcoma (KS)
Lymphoid interstitial pneumonia or lymphoid hyperplasia complex
Burkitt lymphoma
Immunoblastic lymphoma
Primary lymphoma of the brain
Mycobacterium avium complex or Mycobacterium kansasii, disseminated
Mycobacterium tuberculosis of any site in or out of the lungs
Mycobacterium or similar species disseminated beyond the lung
Pneumocystis pneumonia
Pneumonia recurrent
Progressive multifocal leukoencephalopathy (PML)
Salmonella septicemia, recurrent
Toxoplasmosis of the brain
Tuberculosis
Wasting syndrome
None
Hepatitis B Status
* must provide value
antibody protected
isolated core
vaccine non-responder, core negative
chronic hepatitis B
immune controller
unknown
antibody protected
isolated core
vaccine non-responder, core negative
chronic hepatitis B
immune controller
unknown
Which meds do they take for chronic hepatitis B?
Hepatitis C status
* must provide value
known negative
chronic active
on treatment
successfully treated
unknown
known negative
chronic active
on treatment
successfully treated
unknown
Which meds do they take for HCV?
Date of COVID-19 diagnosis?
Today M-D-Y
Patient Location When Tested
* must provide value
Home or standalone testing (e.g., mobile testing site)
Nursing home or Assisted living facility
Outpatient facility
Emergency department
Inpatient/hospital
Unknown
Other
Home or standalone testing (e.g., mobile testing site)
Nursing home or Assisted living facility
Outpatient facility
Emergency department
Inpatient/hospital
Unknown
Other
Other location at which patient was tested
How was diagnosis made?
* must provide value
What other method was used to make COVID-19 diagnosis?
Have they been symptomatic at any time (see symptom list below)
* must provide value
Yes
No
Date of first symptom
* must provide value
Today M-D-Y
Patient symptoms (select all that apply)
* must provide value
COVID-19 Treatment (may check more than 1)
* must provide value
How many days did they receive remdesivir?
How many days did they receive lopinavir/ritonavir?
How many days did they receive chloroquine?
How many days did they receive hydroxychloroquine?
How many days did they receive azithromycin?
How many days did they receive IL-6 inhibitors?
How many days did they receive Bevzcizumab?
How many days did they receive JAK inhibitors?
How many days did they receive serpin inhibitors?
How many days did they receive ciclosenide inhibitors?
How many days did they receive glucocorticoids?
How many doses of IVIG did they receive?
On how many occasions did they receive plasma from COVID recovered patients? (convalescent plasma)
For how many days did they receive therapeutic anticoagulation for treatment of COVID/COVID related complications?
Other Treatment (specify)
* must provide value
Was the patient hospitalized?
* must provide value
Yes
No
Today M-D-Y
Today M-D-Y
Highest level of hospital care
* must provide value
Supportive care (no supplemental O2)
Supplemental O2
High flow O2
Mechanical ventilator
ECMO
Unknown
Other
Supportive care (no supplemental O2)
Supplemental O2
High flow O2
Mechanical ventilator
ECMO
Unknown
Other
Other level of care (specify)
Complications During Hospitalization
* must provide value
Other complications (specify)
What is the patient current status?
* must provide value
Resolved
Symptomatic not hospitalized
Symptomatic remains hospitalized
Deceased
Other
Resolved
Symptomatic not hospitalized
Symptomatic remains hospitalized
Deceased
Other
Today M-D-Y
Other status (specify)
* must provide value
Date of symptom resolution (if known)
Today M-D-Y
Unresolved symptoms (select all that apply)
Today M-D-Y
Infection Acquisition: In the 14 days before onset of illness did the patient have any of the following? (Check all that apply)
* must provide value
If other suspected route of infection, please specify
* must provide value
Are there any laboratory test results available related to this patient's COVID-19 infection?
* must provide value
Yes
No
Absolute WBC count peak during COVID? (k/mm3)
Absolute Neutrophil peak during COVID? (k/uL)
Absolute Lymphocyte nadir during COVID? (k/uL)
Lowest platelet count during COVID? (k/mm3)
Highest ALT during COVID? (IU/L)
Highest AST during COVID? (IU/L)
Highest D-Dimer during COVID? (ng/mL)
Would you like to share any additional information about presentation of this case?
May we contact you if needed to get more information about this case?
Yes
No
Date of Update Report
* must provide value
Today M-D-Y
Did Patient Require Admission to an ICU Within 30 Yes Days of SARS-CoV-2 Testing?
* must provide value
Yes
No
If yes number of Days in ICU
Did the patient require circulatory support Within 30 Days of SARS-CoV-2 Testing?
No circulatory support required
Vasopressors
Mechanical circulatory support
Other
No circulatory support required
Vasopressors
Mechanical circulatory support
Other
If other, please describe
Initial CXR Findings (on or shortly after the day of COVID-19 diagnostic testing) (Select all that apply)
If other findings, please describe
CT Scan Findings (on or shortly after the day of COVID-19 diagnostic testing) (Select all that apply)
If other CT findings, please describe
Please provide result if procalcitonin was performed and resulted (ng/mL)
Please provide result if C-Reactive protein (CRP) was performed and resulted (μg/mL)
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