As soon as possible, notify and send completed form to: 1) your local state health department, and 2 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering today's date and the state ID. Fill in the state and county where the patient resides.
3. Complete the interviewer section with your name, phone number, and email address.
4. Indicate the patient's sex and age, then specify their residency status as either a US resident or non-US resident.
5. Document the date of symptom onset and mark all applicable symptoms from the provided list.
6. Answer questions regarding close contact with known MERS cases or travel history to/from the Arabian Peninsula, providing details as necessary.
7. Fill out any comorbid conditions that apply to the patient and indicate hospitalization status if relevant.
8. Complete laboratory testing sections by marking results for various pathogens and MERS-CoV testing as applicable.

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