Contact Registration Form
Demographics
Family Name:
*
Given Name:
*
Middle Name:
Gender:
*
...
Male
Female
Will Record Date of Birth...
*
...
By Birth-date
By Age
Select Birthdate
*
Is this birthdate an estimate?
*
...
Yes
No
Age:
Years
*
Months
*
Contact identifiers
Unique case identifier:
*
Address
Address:
Section/Homestead:
Village:
Province:
District:
Postal Code:
Country:
Are you currently at the home location of the COVID contact?
...
Yes
No
Pick GPS address
Latitude:
Longitude:
Attributes
Country of residence:
Name of chief:
Country of Birth:
Telephone (mobile) number:
*
Email address:
Occupation
*
Doctor
Nurse
Health laboratory worker
Health worker
Works with animals
Student
Other
Specify:
*
Type of accommodation
*
Shared
Own house
Homeless
Visiting Kenya
Other
Person you have been in contact with
Relationship to person:
...
COVID-19 Potential Exposure to
COVID-19 Potential Exposure from
Person name:
Individual not found on this device. Please select
Search server
option to search this individual on the server. You can also register them as a new client by selecting
Create Person
below.
Individual not found on the server. Please register them as a new client by selecting
Create Person
below.
Search server
Gender:
...
Male
Female
Date Of Birth:
OR
Create person
Does the person have symptoms consistent with COVID-19
*
Yes
No
Unknown
Has the person been in close contact with a case of COVID-19 in the last 14 days?
*
Yes
No
Unknown
Date of last exposure to case
*
Encounter Location:
*
Encounter Location
*
...
Provider Name:
Provider's System Id:
*
Encounter Date
*