Coronavirus disease (COVID-19) technical guidance by WHO Household transmission investigation protocol | Page 38

Form 4: Follow-up reporting form – for confirmed cases and household contacts (Day 28)
Unique Primary Case ID/Household number
Household Contact ID Number (C…):
1. Report of laboratory results (Day 28)
Please impute laboratory results once they become available in the “Laboratory results report”
2. Outcome (Day 28)
Outcome
□ Alive □ Dead □ na □ Unknown
Outcome current as of date (dd/mm/yyyy)
___/___/___
□ Unknown □ na
□ Yes □ No □ Unknown
Hospitalization
If Yes, date of first hospitalization (dd/mm/yyyy)
___/___/___
□ Unknown
If Yes, specify reason for hospitalization:
3. Status of form completion
Form completed
□ Yes □ No or par ally
If No or partially, reason:
□ Missed
□ Not attempted
□ Not performed
□ Refusal
□ Other, specify:
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