Screening 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
Any symptoms
*
Yes
No
Unknown
Date of first symptom
*
We have to ask about some specific symptoms individually
Fever(>=38 or history of fever)
*
Yes
No
Unknown
Date:
*
Sore throat
*
Yes
No
Unknown
Date:
*
Runny nose
*
Yes
No
Unknown
Date:
*
Cough
*
Yes
No
Unknown
Date:
*
Shortness of breath
*
Yes
No
Unknown
Date:
*
Vomiting
*
Yes
No
Unknown
Date:
*
Nausea
*
Yes
No
Unknown
Date:
*
Diarrhoea
*
Yes
No
Unknown
Date:
*
Loss of smell
*
Yes
No
Unknown
Date:
*
Patient has a positive screen. Please follow standard guidelines on testing.
Sample Collection
Has sample been collected
*
Yes
No
Unknown
What type of sample was collected
*
Nasal swab
Throat swab
Nasopharyngeal swab
Serum
Other
None
Unknown
Specify
*
Date sample collected
*
Case status
*
Suspected
Probable
Confirmed
COVID-19 plan
*
None
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:
*