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SCREENING TOOL FOR COVID-19
Electronic Tools for capturing the details of the persons under investigation
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* Indicates required question
Email
*
Your email
Captured By
Your answer
Province
Choose
Eastern Cape
District
Choose
Alfred Nzo
Amathole
Buffalo City Metro
Chris Hani
Joe Gqabi
Nelson Mandela Metro
OR Tambo
Sarah Baartman
Name of Screening Site
Your answer
1. Capture Date
*
MM
/
DD
/
YYYY
DEMOGRAPHIC INFORMATION
Capture the demographics of the person being screened
2. Name
*
Your answer
3. Surname
*
Your answer
4. Date of Birth
MM
/
DD
/
YYYY
5. Physical Address
Your answer
6. Cellphone Number
Your answer
7. Gender
Male
Female
Clear selection
8. Race
Black
White
Other:
Clear selection
9. Type of Dwelling and Size
Your answer
10. Occupation
Scholar
Office worker
Mine worker
Taxi/ Bus/ Truck driver/ conductor
Healthcare Worker
Other:
Clear selection
MEDICAL HISTORY
Tick the appropriate answer, if yes further ask about whether on treatment
11. Medical Condition
Asthma
COAD
HIV
TB
Hypertension/Cardiac Condition
Diabetes
Smoker
Pregnancy Status
Yes
No
Not Applicable
Clear selection
TESTING CRITERIA
12. Did the person travel outside the country before 01 February 2020
Yes
No
Clear selection
13. Did the person travel outside Eastern Cape since March 2020
Yes
No
Clear selection
14. Did the person have any contact with person who is COVID-19 positive
Yes
No
Clear selection
Where was did the contact with the COVID-19 Positive occur?
Choose
Home
Work
Taxi
Bus
Plane
Church
Other
15. RECENT MEDICAL CARE
Did the person recently visit a clinic?
Yes
No
Clear selection
Did the person recently visit a General Practitioner (GP)?
Yes
No
Clear selection
Was the person recently hospitalised?
Yes
No
Clear selection
16. CURRENT SIGNS AND SYMPTOMS
Did the person have any of the following symptoms?
High Temperature (Fever)
Cough
Sore Throat
Shortness of Breath
General weakness (Myalgia)
Loss of taste (Ageusia)
Loss of the sense of smell (anosmia)
Other:
Collect specimen for COVID-19 if:
The answer is yes to any one of question 12, 13 and 14
OR
Any ONE of the 7 symptoms in question 16 are present
OR
A contact (with symptoms) of a current Person Under Investigation (PUI)
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