Exposure Form

{"patient.personattribute":[{"attribute_type_uuid":"8d871d18-c2cc-11de-8d13-0010c6dffd0f","attribute_type_name":"Mother's Name","attribute_value":"Vinolia"}],"patient.personaddress":[{"address1":"address","address2":"homestead","address3":"estate","address4":"division","address5":"sublocation","address6":"location","cityVillage":"town\/village","stateProvince":"province","country":"country","postalCode":"postalcode","countyDistrict":"district","preferred":true,"uuid":"ddc9e83c-1691-11df-97a5-7038c432aabf"}],"patient":{"patient.given_name":"Mitchell","patient.middle_name":"Yebei","patient.family_name":"Cherwon","patient.sex":"F","patient.uuid":"dd5541e2-1691-11df-97a5-7038c432aabf","patient.birth_date":"1978-09-05","patient.medical_record_number":"27KT-7","patient.otheridentifier":[]},"encounter":{"encounter.form_uuid":"cf5b5902-a3b3-4fa3-a414-ad696a035aab","encounter.user_system_id":"admin"}}

Exposure Form

Demographics

Unique Case Id:

Family Name:

Given Name:

Middle Name:

Name:

Gender:

Date Of Birth:

Location where the data collection is/was done *

Domestic Travel

Have you travelled within the last 14 days domestically? *

Yes No Unknown

From date: *

To date: *

Regions visited: *

Cities visited: *

International Travel

Have you travelled within the last 14 days domestically? *

Yes No Unknown

From date: *

To date: *

Country visited: *

Cities visited: *

Covid-19 plan *

None

Complete COVID-19 screening form

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:*