Tracing Form
Demographics
Family Name:
Given Name:
Middle Name:
Name:
Gender:
...
Male
Female
Date of birth:
Age:
Telephone (mobile) number:
Email:
Show address:
Address
Address 1:
Address 2:
City/Village:
State/Province:
County/District:
Postal Code:
Country
Are you currently at the home location of the Covid case?
*
...
Yes
No
Pick GPS address
Latitude:
*
Longitude:
*
Location where the data collection is/was done
*
...
Mobile phone
Health facility
Health clinic
Hospital
Home
En route to health facility
Other
Unknown
Number of attempts
*
...
First attempt
Second attempt
Third attempt
Tracking method
*
Phone
Email
In person
No contact information
Other
Has the close contact person been found?
*
Yes
No
Outcome
*
Declined to answer
Referral declined by patient
Agree with screening
Other
Please proceed with guideline with filling out demographic update form and screening form..
Testing status
*
Positive
Negative
Unknown
Waiting for result
Other
Not tested
Should patient be tracked again
*
Yes
No
Reason:
*
Dead
Exceed maximum attempts
No contact information
Other
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
Please add contacts by selecting
under Client Summary page
Isolation recommended
Quarantine
Refer for admission
Encounter Location:
*
Provider Name:
*
Provider’s System ID:
*
Encounter Date:
*