Name:___________________________________ Date: _____________________________ Municipality: ______________________________________

Date of last Esposure:___________________________________________ Date of Voluntary Quarantine Period Ends: ___________________________________

INSTRUCTIONS: Monitoring shall be done twice a day. Indicate the date; go through each condition for monitoring. Put a Check if the close contact met the condition being
asked under the corresponding time of the day (AM/PM) monitoring was done. Provide the Temperature taken.

Conditions for
Monitoring
AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM

No
Sign/Symptom
fever (temp.)

Cough

Difficulty of
Breathing
Diarrhea

Other
Symptoms
1.
2.
3.
Took Antivirals

Sought Consult

 Quarantine Period ends 14 days after date of Last Exposure