Exposure Form
Demographics
Unique case id:
Family Name:
Given Name:
Middle Name:
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
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 internationally?
*
Yes
No
Unknown
From date:
*
To date:
*
Country visited:
*
Cities visited:
*
In the past 14 days, have you had contact with anyone with suspected or confirmed COVID-19 infection?
*
Yes
No
Unknown
Date of last contact:
*
Patient attended festival or mass gathering in the past 14 days?
*
Yes
No
Unknown
Specify:
*
Patient exposed to person with similar illness in the past 14 days?
*
Yes
No
Unknown
Location of exposure in past 14 days
*
Home
Hospital
Workplace
Tour Group
School
Unknown
Other
Specify:
*
Patient visited or was admitted to inpatient health facility in the past 14 days?
*
Yes
No
Unknown
Specify:
*
Patient visited outpatient treatment facilities in the past 14 days?
*
Yes
No
Unknown
Specify:
*
Patient visited traditional healers in past 14 days?
*
Yes
No
Unknown
Specify:
*
Occupation
*
Health worker
Works with animals
Health laboratory worker
Student
Other
Specify:
*
Covid-19 plan
*
None
Complete COVID-19 screening form
Do yo want to fill screening form now or later
*
Now
Later
Collect laboratory sample
Do yo want to complete laboratory form now or later
*
Now
Later
Refer to laboratory for sample collection
Track close contacts
Isolation recommended
Quarantine
Refer for admission
Encounter Location:
*
Provider Name:
*
Provider’s System ID:
*
Encounter Date:
*