Patient Code: ___(Name)__ Timeline

Name: Age:
Primary Address: VACCINE BRAND: Birthdate:
Secondary Address: IST DOSE: Onset of illness:
Profession: 2ND DOSE: COMORBID:
Company Name: BOOSTER: INDEX CASE:
Office Address:

Date Time Activity Place Close Contact/s Relationship Age Work Symptoms Felt
Annex B. Close Contact Line List Form DATE: REGION: 11
Address: ______________
SUSPECT CASE ID: ____________

CLOSE
NAME (Last Name, First Name, Middle ADRESS NATIONA
CONTACT DATE OF BIRTH AGE SEX (M/F) CONTACT NO. OCCUPATION RELATIONSHIP
Initial) LITY
ID PUROK BARANGAY MUNICIPALITY
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16

LEGEND:
NEG TEST RESULT NEGATIVE
POS TEST RESULT POSITIVE
PENDING RESULT NOT YET KNOWN
N/A NOT TESTED
 DOSAGE SEQ NATURE OF DATE CASE
DATE OF LAST CONTACT ASYMPTOMATIC BEING COVID-19 TEST RESULT COVID-19 DATE TESTING QUARAN CLASSIFIC
VACCINE BRAND IST DOSE 2ND DOSE MONITOR CLOSED
(MM/DD/ TINE INDEX CASE
EXPOSURE (HH, WS, S, (Y/N) ED (Y/N) CENTER FACILITY ATION
DATE DATE T, A, HCW,0) YYYY) PCR RDT PCR RDT