Close Contact Line List Form

Confirmed case #:
Onsset of Illness of Confirmed COVID-19 Case (mm/dd/yyyy)
Date of Last
Nature of
Close Sex Exposure
Middle Date of Birth Contact Asymtoma
Contact Last Name First Name Address Age Contact No.
Initial (mm/dd/yyyy) (HH,WS,S,T,A,HC tic (Y/N)
ID (M/F) (mm/dd/yy
W,O) yy)
1
2
3
4
5
6
7
8
9
10
11
HH:Household;WS:Worksite;S: Sea Vessel; T:Travel; A: Accomodation; HCW:Health Care Worker; O:Others
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