Potential SARS-CoV-2 Reinfection among COVID-19 Cases in the U.S.

The purpose of this query is to facilitate reinfection case description. Please complete as much as feasible.

Please only submit this form if you have specimens available from the initial and recurrent episodes.


          Clinician's Information:
    Your name:
    Your email address:
    Your state of practice:   
    Patient's Demographic Information :
  1. Age group in years:   0-17    18-44    45-54    55-64    >=65
  2. Sex:   Male      Female

  3. COVID-19 Initial Presentation:
  4. Date of onset:   [MM/DD/YY]
    (Note: date of symptom onset or date of first positive SARS-CoV-2 test associated with initial episode if asymptomatic)

  5. Symptoms:   Symptomatic     Asymptomatic

  6. Please describe this case in a few sentences:

  7. COVID-19 Recurrence:
  8. Date of onset:   [MM/DD/YY]
    (Note: date of symptom onset or date of first positive SARS-CoV-2 test associated with initial episode if asymptomatic)

  9. Symptoms:   Symptomatic     Asymptomatic

  10. Close contact with a person known to have laboratory-confirmed COVID-19?
    Yes      No     Unknown

  11. Please describe this case in a few sentences:

  12. SARS-CoV-2 Testing History:
    Date
    collected
    MM/DD/YY
    Test
    type
    Result PCR CT
    value
    Lab report
    available?
    Stored
    sample
    available?
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    May we contact you if more information is necessary to understand your case and if additional steps are needed?   Yes      No

    Telephone number for contact: