Testing 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
Molecular Testing Method and Results Set
Laboratory ID
*
Date sample collected
*
Type of sample
*
...
Nasal Swab
Throat Swab
Nasopharyngeal Swab
Other
Specify
*
Type of test
*
...
PCR
Whole genome sequencing
Partial genome sequencing
Other
Specify
*
Serology Testing Method and Results Set
Laboratory ID
*
Date sample collected
*
Type of sample
*
...
Serum
Other
Specify
*
Type of test
*
...
ELISA
IgM immunoassay
IgM rapid immunoassay
IgG immunoassay
IgG rapid immunoassay
Neutralization assay
Other
Specify
*
Encounter Location:
*
Provider Name:
*
Provider system-id:
*
Encounter Date:
*