COVID- 19 Contract Tracing Sign and Symptom Log Form

Confirmed Case ID: _______________________________ Date:__________________________ Region: _________________________________

Name: ___________________________________________ Date of Birth: ___________________ Cellphone No: ____________________________

Date of Last Exposure: __________________________________ 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 (e.g. 38.3).

Conditions DATE DATE DATE DATE DATE DATE DATE DATE DATE DATE DATE DATE DATE DATE
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

Sore Throat

Difficulty of
Breathing

Colds

Diarrhea

Other
Symptoms
1.
2.
3.

*Quarantine Period Ends 14 days after Date of Last Exposure