Format A - for surveillance of Passenger for 2019-nCoV

(To be filled by District Surveillance Unit and send to SSU daily)

District Anantapuramu Date of Reporting 23.03.2020

Full Name:
Age in years: 26 years Gender: Male
Passport number: R7212732
Complete Address
D.no.24-4-26/5A2,Pipeline Road,Vidyanagar,Hindupur.
(For Indian passport holders)
Place of Stay during visit
…….
(For International tourists)
Landline number with STD code Mobile number
……. 9959014510
(In India) (In India)
Arrived from City / Place Province (State) Country
( Mandatory for China) Angmokio Avenu-5 Singapore
Departure details from 2019- Date Time
nCoV affected country 10/3/20 5:50 AM
Name of the Indian Airport / Time of
Chennai Airport Date: 10.03.20 8:00 AM
Port arrived: Arrival:
FROM TO Date Mode of Travel
Mode of Transport used to reach Chennai Bengaluru 10.03.2020 Flight
the present address from the Airport Airport
above Airport / Port: Bengaluru Hindupur 10.03.2020 Cab
Mode of transport (Flight / Train / Airport
Bus / Cab /Own vehicle etc. )

Other Countries visited in last 28 days

Clinical details: write ‘N’ for No & ‘Y’ for Yes
Day Date Fever Cough Day Date Fever Cough Day Date Fever Cough
1 10.03.20 N N 11 21
2 11.03.20 N N 12 22
3 12.03.20 N N 13 23
4 14 24
5 15 25
6 16 26
7 17 27
8 18 28
9 19
10 20
* In case of any symptoms the passenger should be immediately isolated at designated hospital
* Day 1 should be Date of arrival to India
Source of Information Date of receipt of Information Date observation started
Individual 12.03.20 12.03.20
Filled by Dr.P.C.Naveen Designation Medical Officer

Sample Collected: NO. If Yes,

Hospital where sample is taken: ………. Date ………
Lab where sample sent: ………. Date ………
Result for 2019-nCoV POSITIVE / NEGATIVE Date ………,