Daily Survaillance
Demographics
Unique case id:
Family Name:
Given Name:
Middle Name:
Name:
Gender:
...
Male
Female
Date of birth:
Temperature
*
Symptoms Present
*
Yes
No
Fever(>=38 or history of fever)
*
Yes
No
Unknown
Sore throat
*
Yes
No
Unknown
Runny nose
*
Yes
No
Unknown
Cough
*
Yes
No
Unknown
Shortness of breath
*
Yes
No
Unknown
Vomiting
*
Yes
No
Unknown
Nausea
*
Yes
No
Unknown
Diarrhoea
*
Yes
No
Unknown
Loss of smell
*
Yes
No
Unknown
Outcome
*
Dead
Lost to follow up
Asymptomatic
Symptomatic
Details of lost to follow up
*
Encounter Location:
*
Public Health Team Member:
*
Public Health Team Member's System ID:
*
Date of Surveillance:
*