2019-nCoV Person Under Monitoring

(PUM) Form

Reporting Unit: ____________________________ Date of Interview: ________________

Name of Investigator: ________________________ Investigator Contact Number: _____________________

I. CASE INFORMATION

Name: _________________________________________________ Age: ___ Sex: ___ Birth Date: ____________

(Last Name, First Name, Middle Name) (mm/dd/yy)

Philippine Address: ______________________________________________________________________________

(House No., Block, Purok, Barangay, City, Province)

II. OVERSEAS EMPLOYMENT ADDRESS

Occupation: ________________ Name of Company: ________________________ Contact Nos.: ______________

Address of Workplace: ____________________________________________________________________________

III. HISTORY OF ILLNESS (UPON INTERVIEW) [check which is applicable; if with fever please note the temperature]

Fever ( ) ______ Cough ( ) Colds ( ) Others: (Please specify) _______________________________

IV. TRAVEL HISTORY

(Please indicate City and Country of Origin, Date and Time of Departure, Flight/Vessel Number, Port of Entry and
Arrival Details)

V. EXPOSURE HISTORY
a. Took care, handled specimen and/or lived with a confirmed case of 2019-nCoV infection?
( ) Yes ( ) No ( ) Unknown

b. Working with health care workers infected with health care workers with 2019-nCoV infection?
( ) Yes ( ) No ( ) Unknown

c. Visiting patients or staying in the same close environment as a 2019-nCoV patient?

( ) Yes ( ) No ( ) Unknown

d. Working together in close proximity or sharing the same classroom environment with a 2019-nCoV patient?
( ) Yes ( ) No ( ) Unknown

e. Traveling together with a 2019-nCoV patient in any kind of conveyance?

( ) Yes ( ) No ( ) Unknown

f. Living in the same household as a 2019-nCoV patient?

( ) Yes ( ) No ( ) Unknown

g. Visiting/working in a live animal market in China?

( ) Yes ( ) No ( ) Unknown

h. Direct contact with animals in China with circulating 2019-nCoV in humans and animals?
( ) Yes ( ) No ( ) Unknown
1
 DAILY MONITORING SHEET OF 2019-nCoV ARD Person Under Monitoring (PUM)
SYMPTOMS Monitored By:
(Name, Designation and Signature)
Day
Date & Time of No Remarks
from Sore Runny Shortness
Monitoring symptoms Other symptoms:
Arrival Fever ≥38°C Cough
(checked if none Throat Nose of Breath (Please specify)
experienced)
□ Yes: ____ □ Yes □ Yes □ Yes □ Yes
□ None
□ No □ No □ No □ No □ No
1
□ Yes: ____ □ Yes □ Yes □ Yes □ Yes
□ None
□ No □ No □ No □ No □ No
□ Yes: ____ □ Yes □ Yes □ Yes □ Yes
□ None
□ No □ No □ No □ No □ No
2
□ Yes: ____ □ Yes □ Yes □ Yes □ Yes
□ None
□ No □ No □ No □ No □ No
□ Yes: ____ □ Yes □ Yes □ Yes □ Yes
□ None
□ No □ No □ No □ No □ No
3
□ Yes: ____ □ Yes □ Yes □ Yes □ Yes
□ None
□ No □ No □ No □ No □ No
□ Yes: ____ □ Yes □ Yes □ Yes □ Yes
□ None
□ No □ No □ No □ No □ No
4
□ Yes: ____ □ Yes □ Yes □ Yes □ Yes
□ None
□ No □ No □ No □ No □ No
□ Yes: ____ □ Yes □ Yes □ Yes □ Yes
□ None
□ No □ No □ No □ No □ No
5
□ Yes: ____ □ Yes □ Yes □ Yes □ Yes
□ None
□ No □ No □ No □ No □ No

2
 □ Yes: ____ □ Yes □ Yes □ Yes □ Yes
□ None
□ No □ No □ No □ No □ No
6
□ Yes: ____ □ Yes □ Yes □ Yes □ Yes
□ None
□ No □ No □ No □ No □ No
□ Yes: ____ □ Yes □ Yes □ Yes □ Yes
□ None
□ No □ No □ No □ No □ No
7
□ Yes: ____ □ Yes □ Yes □ Yes □ Yes
□ None
□ No □ No □ No □ No □ No
□ Yes: ____ □ Yes □ Yes □ Yes □ Yes
□ None
□ No □ No □ No □ No □ No
8
□ Yes: ____ □ Yes □ Yes □ Yes □ Yes
□ None
□ No □ No □ No □ No □ No
□ Yes: ____ □ Yes □ Yes □ Yes □ Yes
□ None
□ No □ No □ No □ No □ No
9
□ Yes: ____ □ Yes □ Yes □ Yes □ Yes
□ None
□ No □ No □ No □ No □ No
□ Yes: ____ □ Yes □ Yes □ Yes □ Yes
□ None
□ No □ No □ No □ No □ No
10
□ Yes: ____ □ Yes □ Yes □ Yes □ Yes
□ None
□ No □ No □ No □ No □ No
□ Yes: ____ □ Yes □ Yes □ Yes □ Yes
□ None
□ No □ No □ No □ No □ No
11
□ Yes: ____ □ Yes □ Yes □ Yes □ Yes
□ None
□ No □ No □ No □ No □ No

3
 □ Yes: ____ □ Yes □ Yes □ Yes □ Yes
□ None
□ No □ No □ No □ No □ No
12
□ Yes: ____ □ Yes □ Yes □ Yes □ Yes
□ None
□ No □ No □ No □ No □ No
□ Yes: ____ □ Yes □ Yes □ Yes □ Yes
□ None
□ No □ No □ No □ No □ No
13
□ Yes: ____ □ Yes □ Yes □ Yes □ Yes
□ None
□ No □ No □ No □ No □ No
□ Yes: ____ □ Yes □ Yes □ Yes □ Yes
□ None
□ No □ No □ No □ No □ No
14
□ Yes: ____ □ Yes □ Yes □ Yes □ Yes
□ None
□ No □ No □ No □ No □ No

Note:
1) When the PUM will be feverish or will manifest any flu-like symptoms, they would be now referred as PUI and will be managed accordingly.
2) Please note in the remarks column where would the PUM be transferred for hospitalization.
3) In case that the PUM will be leaving prior the completion of 14-days observation period (i.e returning abroad, etc), please also note that in remarks column.