First names

Surname

Gender (M/F)

Pregnant (yes/no)

Citizenship

ID number

Passport number (if applicable)

Other ID number (if applicable)

Date of birth

Age

Patient HPRS-PRN

Patient File/Folder #

Hospital number (if applicable)

Ward name (if hospitalised)

Residential address

Telephone number

Name and address of employer, school or other institution where patient spends much of the day

Telephone number of employer, school or other institution where patient spends much of the day

Notifiable medical condition diagnosed

Method of diagnosis (clinical, lab, x-ray, other)

ICD10 code

Clinical symptoms

Date of onset of symptoms

Date of diagnosis

Vaccination status

Treatment given

History of possible exposure in the last 60 days (yes/no/unknown)

Specimens collected (yes or no)

Specimen type

Date of specimen collection

Specimen laboratory barcode/number

Patient vital status (alive/deceased)

Date of death

Patient admission status (inpatient/outpatient/discharged)

Transferred to another facility (yes/no)

Name of health establishment if transferred

Places travelled to in the last 60 days (country, province, locality)

Dates travelled to and from the place of travel

Health care provider first name

Health care provider surname

Health care provider practice number

Health care provider mobile number

Health establishment name

Health establishment registration number

Sub-district

District/Municipality

Province

Health establishment contact number

Date of notification