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Contact Tracing Form

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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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Please note that this checklist template is a hypothetical appuses-hero example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.
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