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AgRDT Reporting Form for General Public
Official Antigen RDT reporting form from Epidemiology and Disease Control Division, Ministry of Health and Population, Nepal
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* Indicates required question
Email
*
Your email
Option 1
Clear selection
First Name
*
Your answer
Last name
*
Your answer
Age (in years)
*
Your answer
Sex
*
Male
Female
Other:
Nationality
*
Your answer
District
*
Your answer
Municipality
*
Your answer
Ward No
*
Your answer
Tole
*
Your answer
Occupation
*
Your answer
Contact No.
*
Your answer
Travel History ( Last Visit place in 7 days)
Your answer
Reason for Test
*
Symptomatic without known contact
I was contact of a Case and developed symptoms
I was contact of a Case but no symptoms
Reason for Testing (Optional)
Your answer
Result
*
Positive
Negative
Date of Testing
*
MM
/
DD
/
YYYY
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