Coronavirus disease (COVID-19) technical guidance by WHO Investigation protocol for COVID-19 | Page 17

Population-based age-stratified seroepidemiological investigation protocol for COVID-19 virus
infection
Form 1: Report Form for all participants
Unique ID
1. Data Collector Information
Name of data collector
Data collector Institution
Data collector telephone number
Mobile number
Email
Form completion date (DD/MM/YYYY) ___/___/___
Date of interview with informant (DD/MM/YYYY) ___/___/___
2. Identifier information
First name
Surname
Sex
Date of Birth (DD/MM/YYYY) □ Male □ Female
___/___/___
□ Not known
Telephone (mobile) number
Age (years, months)
Email
Country of residence
Nationality
Ethnicity (optional)
Occupation
Have you had contact with a anyone with suspected
or confirmed COVID-19 virus infection?
□ Yes □ No □ Unknown
If Yes, dates of last contact (DD/MM/YYYY):
___/___/___
3. Symptom history
In the past (X) months, have you had any of the following:
COMMENT: (X) period to cover time since emergence of COVID-19 virus to date of data collection
Fever ≥38°C
Chills
Fatigue
Muscle ache (myalgia)
Sore throat
Cough
Runny nose (rhinorrea)
Shortness of breath (dyspnea)
Wheezing
Chest pain
Other respiratory symptoms
Headache
Nausea/vomiting
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ No
□ No
□ No
□ No
□ No
□ No
□ No
□ No
□ No
□ No
□ No
□ No
□ No
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