Template: Institutional Contact Tracing

Written by Azizah Nurdin | Feb 11, 2020 8:05:03 AM

[Template] Institutional Contact Tracing [PF-ID]

These are some of the details that an organization should attempt to collect when there is a suspected case of infection. This template will provide a means to trace individuals who have been in contact with the "alleged" inflected person.  It is to be recorded so that it will assist the authorities when the "alleged" infected person is identified.

Personal Particulars

 

Need Not Enter Information

Name

NRIC/ Passport No.

S/N

Record Source/ Hospital

Case IC

         

 

Date of Birth

Nationality

Sex

Age

Race

Health Status (Well / Unwell)

 

 

 

 

 

 

 

Residential Address and Contact Details

 

Blk No.

Floor

Unit No.

Building Name

Street

Postal Code

 

 

 

 

 

 

 

Home Tel No.

Office Tel No.

Hand Phone No.

Occupation

 

 

 

 

 

Details of Case Contact

Main Contact Category

Relationship to Case

Location of Exposure

Date of Last Exposure

 

Office Address

Blk No.

Floor

Unit No.

Building Name

Street

Postal Code

 

 

 

 

 

 

 

 

Do Not Need To Enter Information (Optional)

 

To Quarantine?

YES / NO

Start Date

End Date

HQO Number

Remarks* e.g. Wearing N95 mask? Overseas? Referred to CDC?

 

 

 

 

 

 

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Reference Guide

Goh, M. H. (2016). A Manager’s Guide to Implement Your Infectious Disease Business Continuity Plan, 2nd Edition. GMH Pte Ltd.