COVID Community Case Interview Form
Attachment 1
COVID Community Contact Tracing Case Number:
NH/:
Name of person conducting the interview:
Date and time:
Hospitalised
Name:
DOB:
Gender:
□ Confirm name, date of birth and gender
{If the person is under 16 (born after today's date, 2005), ask to speak with a parent or legal guardian. If they are
not with their guardian, get a parent/guardian's name and phone number and call them.]
□ Introduction and role
Do you require an interpreter? □ Yes □ No
[If interpreter required, arrange to call back with an interpreter before continuing the interview]
Do you have any difficulty hearing, understanding or with your speech? □ Yes □ No
If yes, would you like someone else to communicate on your behalf?
[Enter the name of the nominated spokesperson in the table below. Record the relationship and reason for
nominated spokesperson in a note on NCTS)
Next of Kin/ Nominated Spokesperson Contact Details
First name:
Last name:
Contact phone:
Privacy statement
To be read exactly:
I need to collect some information from you so that Auckland Regional Public Health Service can help you and
prevent COV/0-19 spreading.
Your information will be held by us, and we will need to share information with others helping control COV/0-19.
Your personal information will not be shared publicly.
Our full privacy statement is available on our website [no need to read out web address] -
www. a rphs. hea Ith. nz(pu bl ic-hea lth-topics/covid-19 /covid-19-privacy-statem en ti
I can read the full privacy statement to you now, text you the link or I can email it to you -
what do you prefer?
Do you have any questions or concerns about privacy? [record response]
D No privacy concerns and Privacy Statement emailed/texted
D Full Privacy Statement read and agreed
D Person does not agree with privacy script/statement [escalate to medical/nursing team lead]
[Introduction script ends] - read the full Privacy Statement, below, if this is the person's preference:
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COVID Community Contact Tracing Case Number:
NH/:
COVID-19 Privacy Statement
The information collected during any COV/0-19 interview will only be used to help you and prevent COV/0-19
spreading.
Your information will be held by Auckland Regional Public Health Service, other Public Health Units and the Ministry
of Health.
We will need to share information with others involved in controlling COV/0-19, such as your doctor, other health
services, and the Ministry of Health. We will only share information for the purpose of controlling COV/0-19 and no
other reason.
Some information may be made public, like any places and events you have been to. This is to help find people who
may have had contact with you. Your personal information will not be shared publicly.
Your information is protected under the Health Information Privacy Code and other law.
If you wish, you can access your health information. You can ask for it to be corrected if you think it is wrong or
misleading.
You can direct any concerns about the privacy of your health information to the District Health Board Privacy Officer
or the Office of the Privacy Commissioner.
The information we ask you for is important to control the spread of COV/0-19. If you don't provide that
information, controlling COV/0-19 may be more difficult. Sometimes, we can require you to supply us with the
information under the Health Act.
COVID-19 test results
Ethnicity
Ethnicity: arph_newnameofcaseid_arph_ethnicity 1 arph_newnameofcaseid_arph_ethnicity2
□ Ask if ethnicity recorded is correct. If it incorrect, tick those that apply:
□ NZ European
□ Maori
□ Samoan
□ Tongan
□ Niuean
□ Chinese
D Indian
□ Other (specify):
D Fijian
D Fijian Indian
□ Cook Island Maori
[If ethnicity Maori]
What is your iwi or hapu affiliation?
House address:
□ Confirm phone number(s), email and house address.
If not correct, specify:
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COVID Community Contact Tracing Case Number:
NH/:
Primary occupation:
(Includes unemployed, retired, aged care resident, other long-term care resident, child, child at home, parenting a
child at home)
Occupation type (not applicable if retired, aged care resident, unemployed etc):
D Preschool (a child attending or an adult working at the preschool)
□ School (a child attending or an adult working at the school)
D Place of work (all other work locations)
Secondary occupation:
Are you an essential worker? □ Yes D No
Are you a healthcare worker? □ Yes D No
If yes, healthcare worker type:
D Other health care occupation with patient contact
D Nurse
□ Medical doctor
□ Other health care occupation without patient contact
Employer/Institution Details for Primary and Secondary Occupation(s)
Employer name/institution:
Employer name/institution contact phone:
Symptoms
I'm going to read out a list of symptoms. Please let me know which you have at the moment, if any.
Tick all that apply:
D History of fever/chills
□ Runny nose
□ Headache
□ Muscular pain
□ General weakness
□ Shortness of breath
D Irritability/confusion
□ Chest pain
□ Cough
□ Diarrhoea
D Loss of sense of
□ Abdominal pain
smell/taste
□ Sore throat
D Nausea/vomiting
□ Joint pain
Case currently has symptoms
D Yes
□ No
When did you first notice these symptoms? Date that the first symptom started:
[If the case does not have symptoms at the moment but did have symptoms in the last 14 days]
Which date did the symptoms start?:
Which date did the symptoms stop?:
Risk Assessment & Underlying Conditions
Tick all that apply:
D Cardiovascular disease (heart disease, high blood I D Immunodeficiency (weakened immune system, eg. HIV)
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COVID Community Contact Tracing Case Number:
NH/:
pressure)
□ Diabetes
D Renal (kidney) failure
D Liver disease
□ Chronic lung disease
□ Chronic neurological or neuromuscular disease
D Malignancy (cancer)
(brain, spine, nervous system or muscle)
□ Other underlying condition, specify:
Do you take any medication? □ Yes
□ No
[If case says yes]
what do you take that medication for?
Do you visit a specialist? D Yes
□ No
[If case says yes]
for what purpose?
Pregnancy and post-partum
Are you currently pregnant?
It is best to inform your midwife or lead Maternity Carer (LMC) that you have tested positive for COVJD-19.
D Pregnancy, if
yes, trimester:
D Post-partum (less than 6 weeks since giving birth)
Have you had a COVID vaccination? D Yes
D No
[If case says yes]
have you had one or two doses? □ 1 dose
□ 2 doses
[If case says yes]
was the vaccination made by Pfizer or AstraZeneca?
D Pfizer
D AstraZeneca
Overseas Travel
Was the case overseas in the last 14 days
• before having COVID symptoms, or
• before the date the positive test was taken, if they don't have COVID symptoms?
□ Yes 0 No
[If case says yes] record the countries visited in this time period:
Last country visited
2nd last country visited
• Country:
• Country:
• City/region:
• City /region:
• Date arrived:
• Date arrived:
• Date left:
• Date left:
3rd last country visited
• Country:
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COVID Community Contact Tracing Case Number:
NH/:
• City/region:
• Date arrived:
• Date left:
Which date did you arrive in New Zealand?
Which countries do you have passports for?
Country 1:
Country 2:
Country 3:
Flight Details - in New Zealand and Overseas
Did the case go on any flights in New Zealand or overseas in the last 14 days
• before having COVID symptoms, or
•
before the date the positive test was taken, if they don't have COVID symptoms?
□ Yes □ No
[If case says yes, record details of each flight below]
Last flight:
2nd last flight:
• Flight number:
• Flight number:
• Seat number:
• Seat number:
• Date departed:
• Date departed:
3rd last flight:
4th last flight:
• Flight number:
• Flight number:
• Seat number:
• Seat number:
• Date departed:
• Date departed:
Other Risk Factors
Did you visit any health care facilities in the 14 days
D Yes □ No
•
before having COVID symptoms, or
•
before the date your positive test was taken, if you don't have COVID symptoms?
Note: includes visiting a community testing centre (including mobile community testing
centres or vaccination clinics), aged residential care and other residential care facilities.
Check Concerto for GP and hospital.
Have you had close contact with a person with an acute respiratory infection (cold and
D Yes □ No
flu symptoms)?
If yes, where was this? [tick all that apply]:
D Family setting
□ Health care
D Workplace
D Unknown
□ Other (specify)
setting
Have you had close contact with a person who is a confirmed COVID-19 case in New
D Yes □ No
Zealand?
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COVID Community Contact Tracing Case Number:
NH/:
• ask for the person's full name
Family
Healthcare Workplace Unknown
Other (specify)
(and any alternative names)
setting
setting
• ask for a date of birth (if known)
• tick where you saw this person
Case 1 name:
□
□
□
□
□
Case 2 name:
□
□
□
□
□
Case 3 name:
□
□
□
□
□
Isolation
Where will the case be isolating?
Isolation notes:
□ At home
Where is the case currently?
D In a managed isolation facility
Have arrangements been made to move the case to an isolation
facility?
Name of isolation facility:
Date started isolation as a case:
Was the person already in isolation/quarantine
•
before having COVID symptoms, or
•
before the date the positive test was taken, if they don't have COVID symptoms?
D Yes D No
{If yes, tick the reason(s) that apply]:
D Close contact with a case D Travel-related D Alert level criteria D Other, specify:
If the case was already in isolation/quarantine, date this started:
Manaaki/Support (Welfare)
I'm going to read a list of different kinds of manaaki
□ Animal needs
(welfare)/support. let me know if you would like us to □ Communication needs
refer you for support with any of these.
□
D
Taha wairua (spiritual and emotional wellbeing)
Food/kai
□
□ Disability needs
Accommodation
□
D
Other, specify:
Financial support
□ Cultural support
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COVID Community Contact Tracing Case Number:
NH/:
□ Medication(s)
□ Medical needs
Is there anything else that might make it more difficult for you to isolate?
It is important that you look after yourself. This can be a stressful time for you and your whanau/family.
If you need to talk to someone, text or call 1737. This is a free 24-hour Mental Health Support Line to talk with a
trained counsellor.
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COVID Community Contact Tracing Case Number:
NHI:
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COVID Community Contact Tracing Case Number:
NH/:
Household Close Contacts: record details of everyone who currently
lives with the case
If you cannot find a household contact in NCTS do not create a new one. Instead speak to the SSO who will find them for you
First name
Also known as
Last name
DOB
Gender
Telephone number
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COVID Community Contact Tracing Case Number:
NH/:
Has the case downloaded the NZ COVID Tracer app or Rippl? D Yes D No
If the case does not have the app, continue with the interview and directly enter the contact locations into NCTS.
If they do have the app:
• Give the case the data request code - this is the "one-time passcode"
case
• Find this by clicking "submit diary" at the top of the case record in NCTS
00005937
IWN E.x:posu,� EW1H
suomit Diary
•
• Select NZ COVID Tracer or Rippl app from the dropdown menu (depending on which app the case uses)
Enter symptom onset date (if applicable)
• Click "next" to generate code (this will appear on your screen)
NZ COVID Tracer users:
• Ask the case to navigate to "My data" on the app
• Ask them to click "Share my digital diary"
• The user will need to confirm their details to continue
• The user then enters the code in the "data request code" field and presses "Share"
Rippl users:
• Ask the case to click the "History" tab on the home page
• At the bottom of the history tab click "Share my history"
• The user will need to confirm their details to continue
• The user then enters the code in the "data request code" field and presses "Share"
• Refresh the case by clicking on the dropdown arrow and selecting "Refresh Tab", or press FS on your keyboard
The information will now be available in NCTS Contact Locations
Bluetooth - only applies to the NZ COVID Tracer app, Rippl does not have the Bluetooth function
D Does the case have 'Bluetooth tracing' turned on in the NZ COVID Tracer app?
D If yes, inform the case that you will talk to your team lead and let them know if a Bluetooth notification will be shared.
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COVID Community Contact Tracing Case Number:
NH/:
D If yes, when did the case turn on Bluetooth tracing in the app?
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COVID Community Contact Tracing Case Number:
NH/:
COVID case timeline
Day of the
week
Date
Days to/from
-7
-6
-5
-4
-3
-2
-1
+1
+2
+3
+4
+S
+6
+7
+8
+9
+10
symptoms or
positive
COVID test
Soura period:
Source
7 days before symptoms started, or If asymptomatic, 7 days
period
prior to the positive swab
Infectious
Infectious period:
period
• 2 days before symptom onset until the case is isolated, or
• if asymptomatic, 2 days before the positive swab was taken. until the case is isolated
Exposure events: places the case has been while infectious
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COVID Community Contact Tracing Case Number:
NH/:
Infectious Period Contact locations:
Record everywhere the case has been in:
Tools that can be used:
• the 2 days before symptom onset until the case is isolated, or
• Contact tracer app
• if asymptomatic, the 2 days before the positive swab was taken, until the case is
• Calendar/s
isolated
• Message texts
• Internet banking (date of purchase not date of processing)
For each contact location
create an exposure event in NCTS
• Google locations
• Social media: Facebook, Messenger, WhatsApp, lnstagram, Snapchat etc.
If the case has attended any high risk locations in this period, please escalate to team
• Work swipe access records
lead
Name of Case:
location name
Date
Start time
End time
Address
Details
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COVID Community Contact Tracing Case Number:
NH/:
Name of Case:
Location name
Date
Start time
End time
Address
Details
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COVID Community Contact Tracing Case Number:
NH/:
Source Period Contact Locations:
Record high risk locations from
days -2 to -7 prior to onset of symptoms (or if asymptomatic, date that
positive swab was taken).
High risk locations include:
Tools that can be used:
• Hospitals and other healthcare settings (dentists, primary care, pharmacies)
• Contact tracer app
• Aged residential care facilities
• Calendar/s
• Correctional facilities
• Message texts
• Institutions e.g. universities, university hostels, schools, early childhood education centres
• Internet banking (date of purchase not date of processing)
• Google locations
• Hostels (outside of university hostels)
•
Social media: Facebook, Messenger, WhatsApp, lnstagram,
• Residential care facilities
Snapchat etc.
• Places of worship
• Work swipe access records
• Other people's homes
You do not need to record any other locations
Name of Case:
High risk location
name
Date
Start time
End time
Address
Details
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COVID Community Contact Tracing Case Number:
NH/:
Name of Case:
High risk location
name
Date
Start time
End time
Address
Details
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COVID Community Contact Tracing Case Number:
NHI:
Case Interview Checklist
Before Interview
☐ Change the Owner to yourself
☐ Click on the Profile Name (hyperlink to the Profile record) to assess:
•
Age (<16yrs requires parent/guardian)
•
Ethnicity and gender (consider interpreter and/or cultural support)
☐ In Tests Results click on the hyperlink to view details;
•
Check NHI corresponds with case NHI
•
Confirm Test result reflects the Case Classification
☐ Click on the title of the Note/s, and then Files to assess any written details/instructions
☐ Review case information, e.g. history of illness, isolation details
Inform case and investigate
☐ If unable to contact, log any calls or texts using the Log a Call tab on Activity History
☐ Complete hard-copy interview form
☐ Complete the Inform Q&A to update the case information on the left
☐ On the left hand side review every field and edit the information
• Ensure the case interview date and time is the actual date/time, not when the Inform Q&A is done
☐ The yellow sections in the hard copy interview form are not captured in NCTS and must be documented in the field Additional Case information
☐ Document if the case uses the COVID tracer app or Rippl, and do they have ‘Bluetooth tracing’ turned on, and when did they turn it on
☐ Emails should be saved in ‘Files’
☐ Click on the tabs Person Details to review and update any contact Details for the case
☐ If you answered yes to any of the accessibility/assistive devices in the inform Q&A, this will be in the Medical Information section
☐ Discuss interview and exposure events with Team MO
☐ From contact locations create exposure events (where case infectious)
☐ Click on contextual tab ‘Advance to follow up’, complete Team managed by field in the case follow up record
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