Coronavirus disease (COVID-19) technical guidance by WHO Household transmission investigation protocol | Page 29

Form 1A : Case initial reporting from – for confirmed cases (Day 1)
Unique Primary Case ID/Household number
1. Current status
□ Alive □ Dead
2. Data collector information
Name of data collector
Data collector institution
Data collector telephone number
Data collector email
Form completion date (dd/mm/yyyy)
___/___/___
3. Interview respondent information (if the person providing the information is not the primary case)
First name
Family name
Sex □ Male □ Female □ Not known
Date of birth (dd/mm/yyyy) ___/___/___
□ Unknown
Relationship to primary case
Respondent address
Telephone (mobile) number
4. Primary case identifier information
First name
Family name
Sex
Date of birth (dd/mm/yyyy)
Telephone (mobile) number
Age (years, months)
□ Male □ Female □ Not known
___/___/___
□ Unknown
___ years ___ months
□ Unknown
Email
Address
National social number/identifier (if applicable)
Country of residence
Nationality
Ethnicity (optional)
Responsible health centre
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