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Contact Tracing Form Template

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Contact Tracing Form Template

Contact Tracing Form

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
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