Contact Registration Form
Contact Names
Family Name:
*
Given Name:
*
Middle Name:
Contact 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
*
Date of last contact with case:
Type of Contact
*
Working together in close proximity or sharing the same classroom environment with a nCoV patient
Face-to-face contact within 1 meter and for more than 15 minutes
Traveling together with a nCoV patient in any kind of conveyance
Living in the same household as a nCoV patient
Healthcare-associated exposure, including providing direct care for nCoV patients, working with health care workers infected with novel coronavirus, visiting patients, or staying in the same close environment as a nCoV patient
Unknown
Other
Specify:
*
Occupation
Medical Officers
Registrars
Consultant Doctors
Clinical Officers
Nurse
Laboratory Personnel
Other Health worker
Other Hospital Worker
Other
Specify:
*
Enter Facility:
*
What is the COVID Status (of contact)
*
Probable
Confirmed
Suspected
Unknown
Relation to Case
*
Mother
Father
Child
Sibling
Uncle
Aunt
Niece or nephew
Grandparent
Grandkid
Co-worker
Spouse or Partner
Other
Encounter Location:
*
Encounter Location
*
...
Provider Name:
Provider's System Id:
*
Encounter Date
*