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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.