ANNEX E.

CLOSE CONTACT LINE LIST FORM

CONFIRMED CASE ID NUMBER: ____________________________________________________

ONSET OF ILLNESS OF CONFIRMED COVID-19 CASE:
NATURE OF RISK DATE OF
CONTACT FACTOR SWABBED
LAST NAME FIRST NAME MIDDLE ADDRESS DATE OF CONTACT DATE OF SYMPTOMS RESUL DATE OF
NAME AGE/ NUMBER (HH, WS, S, T, A, LAST ASYMPTOMATIC T RESULT
BIRTH HCW, O) (Y/N)
SEX EXPOSUR
(MM/DD/YR) E

HH-HOUSEHOLD; WS- WORK SITE; S-SEA VESSEL; T- TRAVEL; A- ACCOMMODATION; HCW- HEALTHCARE WORKER; O-OTHERS