Testing 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
COVID test conducted:
*
Molecular test
Serological test
Molecular testing method
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
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
*
COVID-19 plan
*
Enter laboratory results
Do you want to fill lab results form now or later
*
Now
Later
Follow-up laboratory results
Encounter Location:
*
Provider Name:
*
Provider’s System ID:
*
Encounter Date:
*