Case Registration Form
Case Names
Family Name:
*
Given Name:
*
Middle Name:
Case Attributes
Telephone (mobile) number:
*
Email address:
Country of residence:
Case Address
County:
...
Sub county:
...
Ward:
...
Village:
Landmark:
Are you currently at the home location of the COVID case?
...
Yes
No
Pick GPS address
Latitude:
Longitude:
Case other demographics
Sex:
*
...
Male
Female
Will Record Date of Birth...
*
...
By Birth-date
By Age
Select Birthdate
*
Is this birthdate an estimate?
*
...
Yes
No
Age:
Years
*
Head of Household
*
Partner or Spouse
Sibling
Grandchild
Self
Other family member
Nephew or Niece
Child
Child
Parent
Other
Specify:
*
Asymptomatic/Symptomatic
*
Asymptomatic
Symptomatic
Date of Symptom Onset:
Location Case Identified
*
MTRH
Other
Specify:
*
Date of Last COVID Test:
*
COVID Test Results
*
Positive
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
Encounter Location:
*
Encounter Location
*
...
Provider Name:
Provider's System Id:
*
Encounter Date
*