Screening Form
Demographics
Unique Case Id:
Family Name:
Given Name:
Middle Name:
Gender:
...
Male
Female
Date Of Birth:
Location where the data collection is/was done
*
...
Health Facility
Health Clinic
Hospital
Home
En route to Health facility
Other
Unknown
Any Symptoms
*
Yes
No
Unknown
Date of first symptom
*
Fever(>=38 or history of fever)
*
Yes
No
Unknown
Sore throat
*
Yes
No
Unknown
Runny Nose
*
Yes
No
Unknown
Cough
*
Yes
No
Unknown
Shortness of breath
*
Yes
No
Unknown
Vomiting
*
Yes
No
Unknown
Nausea
*
Yes
No
Unknown
Diarrhoea
*
Yes
No
Unknown
Loss of Smell
*
Yes
No
Unknown
Patient has a positive screen. Please follow standard guidelines on testing.
Date respiratory sample collected
*
What type of respiratory sample was collected
*
Nasal Swab
Throat Swab
Nasopharyngeal Swab
Other
Specify
*
Has Baseline serum been taken
*
Yes
No
Unknown
Date Baseline serum taken
*
Were other samples taken
*
Yes
No
Unknown
Date other samples taken
*
Type of sample
*
Nasal Swab
Throat Swab
Nasopharyngeal Swab
Serum
Other
Specify
*
Case status
*
Suspected
Probable
Confirmed
Covid-19 plan
*
None
Collect laboratory sample
Refer to laboratory for sample collection
Track close contacts
Isolation recommended
Quarantine
Refer for admission
Encounter Location:
*
Provider Name:
*
Provider system-id:
*
Encounter Date:
*