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    3 Annex-G.-Draft - Profile-of-Contacts - COVID-19 PDF

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    Ernest Jerome Malamion
    This document profiles the demographic and health information of individuals identified as close contacts of confirmed COVID-19 cases. It collects details like name, age, address, known medical conditions, and nature of exposure to the confirmed case. Exposure types include travel via plane, sea vessel, land vehicle, as well as locations like accommodations, food establishments, stores, health facilities, workplaces, and social events. It also documents symptoms and refers symptomatic close contacts to hospitals for evaluation, quarantining the asymptomatic individuals.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    3 Annex-G.-Draft - Profile-of-Contacts - COVID-19 PDF

    Uploaded by

    Ernest Jerome Malamion
    108 views2 pages
    This document profiles the demographic and health information of individuals identified as close contacts of confirmed COVID-19 cases. It collects details like name, age, address, known medical conditions, and nature of exposure to the confirmed case. Exposure types include travel via plane, sea vessel, land vehicle, as well as locations like accommodations, food establishments, stores, health facilities, workplaces, and social events. It also documents symptoms and refers symptomatic close contacts to hospitals for evaluation, quarantining the asymptomatic individuals.

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    3 Annex-G.-Draft_Profile-of-Contacts_COVID-19.pdf

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    This document profiles the demographic and health information of individuals identified as close contacts of confirmed COVID-19 cases. It collects details like name, age, address, known medical conditions, and nature of exposure to the confirmed case. Exposure types include travel via plane, sea vessel, land vehicle, as well as locations like accommodations, food establishments, stores, health facilities, workplaces, and social events. It also documents symptoms and refers symptomatic close contacts to hospitals for evaluation, quarantining the asymptomatic individuals.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    108 views2 pages

    3 Annex-G.-Draft - Profile-of-Contacts - COVID-19 PDF

    Uploaded by

    Ernest Jerome Malamion
    This document profiles the demographic and health information of individuals identified as close contacts of confirmed COVID-19 cases. It collects details like name, age, address, known medical conditions, and nature of exposure to the confirmed case. Exposure types include travel via plane, sea vessel, land vehicle, as well as locations like accommodations, food establishments, stores, health facilities, workplaces, and social events. It also documents symptoms and refers symptomatic close contacts to hospitals for evaluation, quarantining the asymptomatic individuals.

    Copyright:

    © All Rights Reserved
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    Download as pdf or txt
    of 2

    Republic of the Philippines

    Department of Health

    PROFILE OF THE COVID-19 CLOSE CONTACTS


    Use black or blue pen only. Write clearly in BLOCK letters. Place X in all applicable boxes.

    DEMOGRAPHIC PROFILE

    NAME: _____________________________________________________ NATIONALITY: _________________


    Last Name Given Name Middle Name

    AGE: __________ SEX: Male Female Pregnant Trimester: ___________________________

    DATE OF BIRTH: __________________ CIVIL STATUS: _______________ RELIGION: _________________


    MM / DD / YYYY

    HOME ADDRESS: __________________________________________________________________________


    House No., Bldg. No., Street Name Barangay MunCity Province Region

    CONTACT DETAILS: ___________________ _________________ EMAIL ADDRESS: _______________________


    Home Telephone No. Mobile No.

    Confirmed Case ID: ___________________________ Date of Onset of Illness (mm/dd/yyy): _____________________

    HEALTH PROFILE
    KNOWN MEDICAL CONDITION/S AND MEDICAL HISTORY:
    ___________________________________________________________________________________________
    ____________________________________________________________________________
    CURRENT MEDICATION/S: BLOOD TYPE:

    ___________________________________________________________________ ___________________

    NATURE OF EXPOSURE (Select All That Applies)

    Plane Airline:___________ Flight No.:__________ Route:_____________ Date of Last Exposure: ___/___/____


    Crew Passenger Seat No.: ________ Within 4-rows: Yes No If crew: In-flight Ground

    Sea Vessel Name of Sea Vessel:___________ Vessel No.:__________ Route:___________


    Date of Last Exposure: ___/___/____ Crew Passenger Seat No.: ________ Within 4-rows: Yes No
    If crew: In-flight Ground

    Land Vehicle Specify type:___________ Route:_____________ Date of Last Exposure: ___/___/____


    Crew Passenger Seat No.: ________ Within 4-rows: Yes No If crew: Driver Conductor

    Accommodation Specify type:___________ Name:_____________________ Date of Last Exposure: ___/___/____


    Address: ______________________________________________ Guest Hotel worker: ______________
    MunCity Province Region

    Food Establishment Specify type:___________ Name:__________________ Date of Last Exposure: ___/___/____


    Address: ______________________________________________ Diner Crew: ______________
    MunCity Province Region

    Store Specify type:___________ Name:______________________________ Date of Last Exposure: ___/___/____


    Address: ______________________________________________ Customer Worker: ______________
    MunCity Province Region

    Health Facility Specify type:___________ Name:______________________ Date of Last Exposure: ___/___/____


    Address: ____________________________________________ Patient Health Worker: ________________
    MunCity Province Region If health worker, fill-out assessment of risk of exposure WHO form

    Event Specify type:___________ Event place:_________________________ Date of Last Exposure: ___/___/____


    Workplace Company Name:_______________________ Address: ____________________________________
    MunCity Province Region
    Date of Last Exposure: ___/___/____

    <Health Status Assessment on Page 2>

    Page 1 of 2
    Symptomatic (Fever or Respiratory Infection or Diarrhea): A. 14 days prior to first date of exposure
    B. Anytime during date of exposure

    Date Onset of Illness: ___/___/____

    Select all that applies:

    Yes No Attendance in social events/ gatherings within two weeks from onset of illness
    If yes, where: _______________________ Date: ___/___/____

    Yes No Travelled outside the province within two weeks from onset of illness
    If yes, where: _______________________ From Date: ___/___/____ - To Date: ___/___/____

    Yes No Travelled outside the country within two weeks from onset of illness
    If yes, where: _______________________ From Date: ___/___/____ - To Date: ___/___/____

    Symptomatic within 14 days after last date of exposure: Yes No

    If yes, Date Onset of Illness: ___/___/____ Name of Referral Hospital:___________________________


    Date of Referral: ___/___/____

    If no, Place of Quarantine: Home Quarantine Facility, specify: ______________________________

    Assessed by: ____________________________________ Date Assessed: ___/___/____


    (Name and Signature)

    <Proceed to Fill-out COVID-19 Contact Tracing Sign and Symptom Log Form>

    Page 1 of 2

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