Title Page

  • Case ID

  • Name

  • Location
  • Date

  • Form Accomplished By

Case Information

Personal Details

  • First Name

  • Surname

  • Age

  • Contact number

  • Alternative contact number

  • Email

  • Address


  • 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

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.