Case Information

Personal Details

First Name

Surname

Age

Contact number

Alternative contact number

Email

Address
Symptoms
Symptom Onset

Please select all symptoms you are currently experiencing

Cough

Fever

Sore throat

Shortness of breath

Runny nose

Fatigue

Loss of smell/or taste

Other symptoms

No symptoms

Location/s visited (if applicable)
Location
Date Visited
Time Arrived
Time Departed
Close Contacts Information

Name

Age

Relation to Case

Last Contact with Case
Address
Contact Number
Emergency Contact Information

Full Name

Relationship

Contact number

Alternative contact number

Email

Address
Final Remarks

Comments

Person Under Investigation
Assigned Contact Tracer
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.