JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
COVID-19 Investigation form CLINA LANCET
Please note payment for covid-19 test is none refundable
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Is this the first time you are getting tested for COVID-19
*
Yes
No
If No, please give the date of your last test
MM
/
DD
/
YYYY
Location of lab test (Laboratory, Health facility, home etc)
Your answer
Case ID
FOR OFFICIAL USE ONLY
Your answer
REFERRING ORGANISATION/FACILITY
Your answer
EPID Number
FOR OFFICIAL USE ONLY
Your answer
Why are you getting tested
*
Your answer
First Name
*
Your answer
Surname
*
Your answer
Date of Birth
*
Month, day, year
MM
/
DD
/
YYYY
Age
*
Your answer
Gender
*
Male
Female
Nationality
*
Nigerian
Other:
Specify Nationality if not Nigerian
Your answer
Home Address
*
Your answer
LGA
*
Your answer
Office Address
*
Your answer
Section/Unit
Your answer
Personal Phone number
*
Your answer
Name of next-of-kin
*
Your answer
Next-of-kin phone number
*
Your answer
Next
Page 1 of 7
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
