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Covid-19 Case Investigation Form (PMLCH)

SECTION 1 : Reporting Officer's Information

Does the Person meets the Case Definition?
Case Classification
Case Category

SECTION 2 : Staff or Patient's information

SECTION 3 : Clinical Information

Do you have any Symptoms?
Admited to Hospital
Was Patient or Staff Ventilated?
Signs Observed
Any comorbidity or preexisting medical condition

SECTION 4 : Exposure and travel information in the 14 days prior to symptoms onset

Has the patient or Staff travelled in the 14 day prior to symptom onset?
Has the Staff or patient had close contact with a person with acute respiratory infection in the 14 days prior to symptom onset?
Has the Staff had contact with a probable or confirmed case in days prior to symptom onset
Have you visited any live animal markets in the 14 days prior to symptom onset?

SECTION 4 : Official Use

Thanks for submitting!

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