CONFIRMED CASE DETA

NAME
SEX CATEGORY (Confirmed,
NO. BDATE NATIONALITY CONTACT NO. Probable, Suspected)
RANK /CIV Last First Middle Qualifier (F/M)

FORMAT:
MONTH/DAY/YEAR SPECIFICALLY CONFIRMED
CODE NO. OF +COVID19: MM/DD/YYYY CASES ONLY
UNIT/PROVINCE+NO.
EX. LAG01
(1 CODE PER PATIENT)

GENERAL INSTRUCTION:

* ONE DOCUMENT PER CONFIRMED COVID-19 PATIENT - SAVE DOCUMENT AS FILE NAME, EX: LAG01 PAT DELA CRUZ, JUAN, THEN SAVE AS TYPE: EXCEL 97-2003
* CONTACT TRACING MUST BE CONDUCTED TO THE MOST RECENT CONFIRMED CASE.
* DO NOT CHANGE / ALTER ANY PART OF THE FORMAT.
* STRICTLY FOLLOW WHAT IS DIRECTED IN THE NOTE BOX.
* ENCODE YOU DATA ACCURATELY AND COMPLETELY. IN ALL CAPITAL LETTERS.
* STRICT OBSERVANCE OF THE PROMPT SUBMISSION OF NEW CONFIRMED CASES, IF ANY.
* EXERT MAXIMUM EFFORT TO GATHER DATA
GENERAL INSTRUCTION:
* ONE DOCUMENT PER CONFIRMED COVID-19 PATIENT - SAVE DOCUMENT AS FILE NAME, EX: LAG01 PAT DELA CRUZ, JUAN, THEN SAVE AS TYPE: EXCEL 97-2003
* CONTACT TRACING MUST BE CONDUCTED TO THE MOST RECENT CONFIRMED CASE.
* DO NOT CHANGE / ALTER ANY PART OF THE FORMAT.
* STRICTLY FOLLOW WHAT IS DIRECTED IN THE NOTE BOX.
* ENCODE YOU DATA ACCURATELY AND COMPLETELY. IN ALL CAPITAL LETTERS.
* STRICT OBSERVANCE OF THE PROMPT SUBMISSION OF NEW CONFIRMED CASES, IF ANY.
* EXERT MAXIMUM EFFORT TO GATHER DATA
D CASE DETAILS
ADDRESS
REMARKS DATE
No. Street Brgy Municipality / City Province Longtitude Latitude

REFER TO CIRAS PERSONNEL PATIENT STATUS:

NFIRMED DIED
LY FOR EXACT LOCATION
HOSPITALIZED/ADMITTED
(INDICATE HOSPITAL NAME)

HOME QUARANTINE
(INDICATE DATE STARTED)

DATE : MM/DD/YYYY

TIME: HH:MIN (SPAC

EVENT: INDICATE WH

EXCEL 97-2003 PLACE OF EVENT: IND

TRAVEL HISTORY: N F
YI

NOTE: START THE BA

DECLARED CO

EXAMPLE:
DATE CONFIRM
COVERAGE OF
 DATE : MM/DD/YYYY
TIME: HH:MIN (SPAC

EVENT: INDICATE WH

EXCEL 97-2003 PLACE OF EVENT: IND

TRAVEL HISTORY: N F
YI

NOTE: START THE BA

DECLARED CO

EXAMPLE:
DATE CONFIRM
COVERAGE OF
 ACTIVITIES CONT
WITH TRAVEL NAME2
TIME EVENT PLACE OF EVENT HISTORY (Y/N)? NO2.
RANK/CIV Last First Middle

: MM/DD/YYYY

HH:MIN (SPACE) AM/PM

T: INDICATE WHAT KIND OF ACTIVITIES (EXAMPLE: MARKET, WORK, VISIT ETC.)

OF EVENT: INDICATE THE LOCATION/ADDRESS OF ACTIVITIES/EVENT

EL HISTORY: N FOR NONE

Y IF THERE IS ANY (INDICATE WHAT COUNTRY / PROVINCE / CITY)

: START THE BACK TRACKING OF EVENT/ACTIVITY FROM THE DAY THE PATIENT WAS
DECLARED CONFIRMED FOR 14 DAYS.

EXAMPLE:
DATE CONFIRMED - APRIL 15, 2020
COVERAGE OF BACK TRACKING - APRIL 1, 2,3...- 14, 2020
: MM/DD/YYYY
HH:MIN (SPACE) AM/PM

T: INDICATE WHAT KIND OF ACTIVITIES (EXAMPLE: MARKET, WORK, VISIT ETC.)

OF EVENT: INDICATE THE LOCATION/ADDRESS OF ACTIVITIES/EVENT

EL HISTORY: N FOR NONE

Y IF THERE IS ANY (INDICATE WHAT COUNTRY / PROVINCE / CITY)

: START THE BACK TRACKING OF EVENT/ACTIVITY FROM THE DAY THE PATIENT WAS
DECLARED CONFIRMED FOR 14 DAYS.

EXAMPLE:
DATE CONFIRMED - APRIL 15, 2020
COVERAGE OF BACK TRACKING - APRIL 1, 2,3...- 14, 2020
CONTACTED PERSON/S SYMPTOMS (Y/N)?

SEX CATEGORY (Confirmed, Difficult to Sore Runny

RELATIONSHIP BDATE2 NATIONALITY CONTACT NO.2 Fever Cough Headache
Qualifier (F/M) Probable, Suspected) Breath Throat Nose
 REMARKS
Diarrhea Fatigue
 CONFIRMED CASE DETAILS

NAME
NO. RANK /
LAST FIRST MIDDLE QUALIFIER
CIV
1

SEX BIRTH DATE NATIONALITY CONTACT NO. CATEGORY

O MALE O CONFIRMED
O FEMALE O PROBABLE
O SUSPECTED

ADDRESS:
NO. STREET BRGY. MUNICIPALITY / CITY PROVINCE

Disease Reporting UnitName of Investigator: Date of Interview:

CLINICAL INFORMATION
Disposition Health Sta Date of Onset of Illness Date of Admission/Consultation With Fever? (°C) With Cough?
O Unknown O Asymptomatic
O Inpatient O Mild
O Outpatient O Severe With Sore Throat? With Colds? With Difficulty of Breathing? High Risk
O Discharged O Critical Yes/NO
O Died
Start Date of Quarantine Type Quarantine Location

WITH TRAVEL HISTORY (DETAILS)?

NONE.

REMARKS

CONFIRMED CASE DETAIL

 LAST
DIRECT STATUS (HOME COVID-19
WITH
UNIT CONTACT SIGNS/ QUARANTINE/ FIRST TEST
TRAVEL RESULT OF
ASSIGN NAME AGE SEX ADDRESS OF AN SYMPTOMS ADMITTED AT (DATE) AND
HISTORY(Y/ COVID-19 TEST
MENT ALLEGED (DATE) (NAME) (DATE) OF
N)
COVID-19 HOSPITAL REPEAT TEST
PATIENT
 ACTIVITIES
DATE
TIME
PLACE

NAME CATEGORY (/) SYMPTOMS (Y/N)?

SEX BIRTH
NO. RANK/ RELATIONSHIP NATIONALITY CONTACT NO. DIFFICULT SORE RUNNY REMARKS
CIV LAST FIRST MIDDLE QUALIFIER (F/M) DATE CONFIRMED PROBABLE SUSPECTED FEVER COUGH
TO BREATH THROAT
HEADACHE
NOSE
DIARRHEA FATIGUE