Coronavirus Case Report Form

A structured form for documenting a suspected COVID-19 case, capturing details about the person filing the report and the person being reported.

Use this template

Reporter Name

Nombre

Apellido

Reporter Phone Number

Reported Name

Nombre

Apellido

Reported Phone Number

Report Date & Time

When did you first suspect it?

Why are you reporting this person?

Fever Cough Difficulty breathing Known contact with a confirmed case Recent travel history Other reason

Comments

Related templates