Client Information

Identity No. / Hospital No. *
Surname *
First Name *
Age
Date of Birth *
Gender *
Nationality
Residence status
Contact Number *
Client’s email address
Consent to Email Results Notification

Submitter Information (Contact Person For Results)

Surname
First Name
Facility / Hospital / Site
City / Village
Contact Number
Email Address
Results Key Contact
Clients Occupation
Client’s Employer
Client’s Employer Contacts
Residential Plot No.
Location/Area

Specimen Details

Specimen Collection Date
Time Collection

Specimen Type:

RECEIVED BY
DATE
TIME

Laboratory Test Details

Tests Required:

Clinical Presentation and Outcome

Date of Symptom onset:

Clinical Diagnosis:

Symptoms:

Underlying Risk Factors:

Case Classification

Hospitalization




Outcome




Exposure History

Did the patient travel in the 14 days prior to symptom onset?

Travel 1) Area/ Country travelled to:
To Date
From Date
Travel 2) Area/ Country travelled to:
To Date
From Date

Did the client have exposure contact in the 14 days prior to symptom onset?

Type of Exposure
Date of exposure
Other Indications
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