Contact Tracing Form

As part of contact tracing into a confirmed / suspected (possible contagious) case of COVID-19, we are following up with individuals who had contact with you

Basic Information

  * Type / الصله بالمدينة
  * Gender / النوع
* Name / الإسم
* ID Number / رقم الهوية

MRN / رقم الملف الطبي

Age / العمر

Nationality / الجنسية
* Mobile No / رقم الجوال
* Vaccination Type / نوع اللقاح
* Vaccination Status / حالة التطعيم
* Case Definition / تعريف الحالة
Initial Swab Date / تاريخ المسحه الأولي

Result Date / تاريخ النتيجه

Travel history in last 14days / سجل السفر في آخر 14 يومًا

Symptoms Information

We are also calling to check on you and discuss some Health recommendations with you.
Do you have experienced fever, cough, sore throat, shortness of breath, vomiting, diarrhea, or any other symptoms? If yes check box and ask about onset date and findings
Upper Respiratory / التنفس العلوي

General / عام

Gastrointestinal / الجهاز الهضمي

History Information

Do you have any known medical history? / هل لديك تاريخ مرضى

Known History of Contact to Covid positive patient in last 10 days
Living Place (City or Outside/if City exact location) / مكان الأقامة
- Identify Contacts: We are identifying individuals who may have been present at or have met with you 2 days prior 2 to onset of your symptoms or (if no symptoms 2 days prior to your swab date at Work, Residence, Event, Meeting, Eating etc

Identify Contacts / بيانات المخالطين

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