COVID Cases Registration Form
Frequency of filling out this Form for a particular case: Once
Location where the data collection is/was done:
*
...
Health facility
Health clinic
Hospital
Home
En Route to health facility
Other
Unknown
Case current status
*
...
Alive
Dead
COVID status:
*
...
Suspected
Probable
Confirmed
Source of Information provided by
*
...
Self
Other
Please specify information provided by:
*
Case Names
First Name:
*
Family Name:
*
Other Name:
Case Attributes
Telephone (mobile) number:
Email Address:
Country of residence:
Case Address
Address 1:
Address 2:
City/Village:
State/Province:
County:
Postal Code:
Are you currently at the home location of the Covid case?
*
...
Yes
No
Latitude:
*
Longitude:
*
Case Identifiers
Unique case identifier:
*
Case Other Identifiers:
Identifier Type
...
National social number/identifier
Enter Identifier
Confirm Identifier
Case other demographics
Sex:
*
...
Male
Female
Will Record Date of Birth...
*
...
By Birth-date
By Age
Select Birthdate
*
Is this birthdate an estimate?
*
...
Yes
No
Age:
Years
*
Months
*
Contact persons details
Relationship type:
*
...
aaaa
Person name:
Gender:
...
Male
Female
Date Of Birth:
OR
Create person
Encounter Location:
*
Encounter Location
*
...
Provider Name:
Provider's system-id:
*
Encounter Date
*