Contact Tracing Form Template

• Case ID

• Name

• Location
  Address

• Date

  Date

• Form Accomplished By

Personal Details

• First Name

• Surname

• Age

• Contact number

• Alternative contact number

• Email

• Address
  Address

Symptoms

• Symptom Onset

  Date

• 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
  Address

• Date Visited

  Date

• Time Arrived

  Date

• Time Departed

  Date
Close Contacts Information

• Name

• Age

• Relation to Case

• Last Contact with Case

  Date
• Address
  Address
• Contact Number
  Address

Emergency Contact Information

• Full Name

• Relationship

• Contact number

• Alternative contact number

• Email

• Address
  Address

Final Remarks

• Comments

• Person Under Investigation

  Sign

• Assigned Contact Tracer

  Sign