TESTING LAB NAME:

REASON FOR TESTING: 1. CASE ID TYPE OF CASE SAMPLE

Surveillance (INITIAL/REPEAT) NUMBER
2. Air Travel
3. Truck Driver
4. Other

2 Initial C126495734
NAME ID/PASSPORT NUMBER

Mr Philip Francis Norman 560678096

Mr Francis Sidney Howard Goldwyn 546214332
Mr Inigo Del Campo Baiges PAJ787191
Jacqueline A Dzaluk 591427385
AGE AGE UNIT GENDER PHONE NUMBER
(DAYS/MONTHS/Y (M/F)
EARS)

48 YEARS M
66 YEARS M
18 YEARS M
63 YEARS M
 COVID-19 RESULTS SUBMISSIO
OCCUPATION NATIONALITY COUNTY OF RESIDENCE

KENYA Nairobi
ULTS SUBMISSION FORM
SUB COUNTY OF VILLAGE/ESTATE OF WARD COUNTY OF
RESIDENCE RESIDENCE DIAGNOSIS

Nairobi
 Note: All headers in Red are required to be filled

HAS TRAVEL TRAVEL FROM CONTACT WITH CASE CONFIRMED CASE NAME
HOSTORY(LAST 14 Y/N
DAYS) Y/N

NO NO
QUARANTINE HAVE SYMPTOMS DATE OF ONSET OF
FACILITY/HOSPITAL/HOMESTEAD Y/N SYMPTOMS

NO
 Version 3
Effective : December 2020

SYMTOMS SHOWN SAMPLE TYPE (NP SWAB, OP DATE OF SAMPLE

(COUGH;FEVER;ETC) SWAB, SERUM SPUTUM ETC) COLLECTION
(DD/MM/YYYY)

NP SWAB 9/2/2021
DATE SAMPLE RECEIVED IN RESULT LAB CONFIRMATION DATE
THE LAB (DD/MM/YYYY)
(DD/MM/YYYY)

9/2/2021 NEGATIVE 9/2/2021

EMAIL ADDRESS

philip.norman@clydeco.com
wambuiwanjiru93@gmail.com
karowl20@gmail.com
wambuiwanjiru93@gmail.com
Field
Reason for testing
CASE ID
TYPE OF CASE (INITIAL/REPEAT)
SAMPLE NUMBER
NAME
ID/PASSPORT NUMBER
AGE
AGE UNIT (DAYS/MONTHS/YEARS)
GENDER
PHONE NUMBER
OCCUPATION
NATIONALITY
COUNTY OF RESIDENCE
SUB COUNTY OF RESIDENCE
VILLAGE/ESTATE OF RESIDENCE
WARD
COUNTY OF DIAGNOSIS
HAS TRAVEL HOSTORY(LAST 14 DAYS) Y/N
TRAVEL FROM
CONTACT WITH CASE Y/N
CONFIRMED CASE NAME
QUARANTINE FACILITY/HOSPITAL
HAVE SYMPTOMS Y/N
DATE OF ONSET OF SYMPTOMS
SYMTOMS SHOWN (COUGH;FEVER;ETC)
SAMPLE TYPE (NP SWAB, OP SWAB, SERUM SPUTUM ETC)
DATE OF SAMPLE COLLECTION
RESULT(Positive/Negative)
LAB CONFIRMATION DATE
Email Address
Expected Data
Indicate the reason why the test is being conducted, type a value in the sheet corresponding to the testing reason ie
Case Identifier as indicated on the case investigation form
Indicate whether the case is an initial or Repeat
Sample Number as used by the testing lab
Client Name
Client ID number or Passport Number
Age
Age provided whether in Years, Months, Days
Client Sex at birth as indicated on the CIF
Client Phone Number
What work the patient does
Country of origin of the patient
Sub County where the patient resides
Sub County where the patient resides
Village or estate where the patient routinely stays
ward where the patient routinely stays
County where the case was diagonised at / Isolated
If the patient has travelled within 14 days indicate 'Y' else indicate 'N'
If the patient has travelled within 14 days indicate where they travelled from
If the patient has been in contact with a confirmed case indicate 'Y' else indicate 'N'
Name of the case the patient came in contact with
Indicate the quarantine facility or hospital where the patient is. If at home indicate Household
If the patient has shown any symptoms indicate 'Y', else indicate 'N'
if the patient has symptoms, indicate when these symptoms started showing
indicate the symptoms shown, list them separated by a semi colon (;)
indicate the sample type
Date when the sample was collected
results of testing
Date when the testing was done
The email address for the client
to the testing reason ie 1 for survbeillance etc