contact tracing form pdf

��I��X �c�8"��ľ �h !yH� ��tALq� � !�$f $b��@�20��Ч /�� Please note, lessons must be completed in order from one to four. The government will use this information to contact you if someone you were seated close to develops coronavirus (COVID-19) symptoms. Use JotForm’s drag-and-drop Form Builder to customize your Contact Tracing Form by adding your logo, including extra questions, or even changing fonts and colors. The Contact Tracing survey will help track down people who are in danger of being exposed to the virus. Authorised. JotForm’s free online Coronavirus Response Forms help healthcare organizations, nonprofits, and government agencies collect the information they need — without the need for back and forth phone calls, emails, or exposing more people to the coronavirus. Determine if contacts will be prioritized for follow-up, including when outreach will be automated vs. done in-person. 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Learning objectives: 1. contact tracing program as part of the public health response. U.S. state and local health departments can use this playbook to rapidly set up and implement contact tracing programs for successful COVID-19 containment. Each day, personnel responsible for destruction should refer to the log form, verify expiry date and prepare collection forms to be destroyed that day. Rapidly identify all potential contacts, 2. contact tracing, gain an understanding of the steps involved, and become aware of the importance of confidentiality. endobj . All contact tracing documents for COVID-19 refer to close contacts of confirmed cases. ��T3 h�UM��;X�&��^3�d�\�8��9�Eo�vو��m��Lu��~�6lH�XМ��,)�p|��r��vi��`sh�-�Wx9��M��\�|�{��g��["�8F��2� �`j��gzh��i&Dqq�xc0c��h��b%�5��`��0�HD��l\�� ^K C��iO��b266� `� fever, cough, sore throat, shortness of breath, sneezing, runny nose or loss of sense of smell) • They have COVID-19 or are awaiting the results from being tested for COVID-19 4057 0 obj <>/Filter/FlateDecode/ID[<7BBB5C02FD4F7C4BBC5431587B95661A>]/Index[4032 55]/Info 4031 0 R/Length 113/Prev 403194/Root 4033 0 R/Size 4087/Type/XRef/W[1 2 1]>>stream 7�0�A��`w��Ǯ+��Ƕ��g��vZ�ͽm��8��=� ��m��k�\-91'��&5̫p4�R Introduction . III. ��. Overview. The document will also assist in estimating the resources required for conducting contact tracing as well as monitoring performance of contact tracing activities. Contact tracing is a key strategy for interrupting chains of transmission of SARS-CoV-2 and reducing COVID-19-associated mortality. A contact tracing form should be completed for each contact to collect relevant demographic. 4 0 obj contact tracing activities in all affected communities. �f-�� %%EOF September, 2020 . Most cases of COVID-19 in New Zealand have come from overseas. Contact Tracing Form. Keep your data HIPAA-compliant by opting for a Silver or Gold plan, or apply for the Coronavirus Responder Program to get a free, unlimited, HIPAA-compliant account. You’ll need to cut out each entry for visitors to write on, and have your own ballot box to put them in. Those regulated by the LTFRB can use the same space to include the information you are required to display: (a) plate number or body number of the vehicle; (b) date and time of boarding; and (c) route. 1.,neCK IT Email Phone# Address Employee . h�bbd``b`Y$ŀ��HpL�kAE@�} The Association and Team collecting this information will not use this information for any other … A contact tracing form is a document that helps health professionals determine who a sick person caught an illness from and track every possible person they have been in contact with while infectious. %�� A pub is required to collect customers’ personal details for the purpose of assisting with local contact tracing requirements. Record sheet: Visitor and patron contact log. %PDF-1.7 Contact Tracing Reg-Form_29/09 Customers should not enter the premises if: • They have any symptoms associated with COVID-19 (e.g. systematic contact tracing. x��r�F��U�[�s��r�J��J6N�dk+��$nd�K�v��.3��2Ea�鞞��:9�l��6z��l��ή�y��j��j��n��/��Ϋ��i��W��?KE��J��4��3/U��?��_��gߝ?v�VF�+��$ܗF22&��r� #��w��挮跢��g��'�"��&R��(��n=OL�d"Ul�<>I��7 ��R�= ��"$�L��$��lR��pt,�Gb�+�*��i�`��U�|@��Qz$�HY�]h�0C�h 11/4/20 ... You will be called by a representative of the New York State Contact Tracing Program. oh�>�Ʊ��f+��`�k��1�9G2"�;#ɌǬ��yE|��Z�� ]�2��c��;�¥"k�W>�(/��@��`E&��T.��̀Di�W��H��%~�i�� v$]n�T8A>��)��E2��ۀ0��3��h��n��|"W�-��,yp��l� �$P"��H��W��Ox�g��oUR��i��K��*��2!Y�Г�d4�s��_�U�篒Z2��}�E"s^"�^]O�,�i ��*ӯ��o��*"%wM�o�Q �K��y�f��z�x��!7�5iE�6(jb��S�� What’s important is that the customer gets to read it. Trace any possible contact a person may have had with anyone who could be a carrier of the COVID-19 virus. 4086 0 obj <>stream COVID-19 Contact Tracing Information Please note this form needs to be completed by all passengers regardless of whether you are travelling onto Spain, another country or remaining in Gibraltar. <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> They . endstream endobj startxref CONTACT TRACING RECORD – ATTENDANCE AT PUBLIC ACTIVITIES * These records must be retained and if requested, be produced to an . Contact tracing register — individual entries for a ballot box [PDF, 1.5 MB] All persons identified as having had contact with a confirmed case during the infectious period should be assessed to see if they should be classified as a close or casual contact. This can lead to timely detection and treatment, as well as preventing it from spreading further. Staff at the pub collect basic information such as a name and contact number from people. It helps effectively carry out the contact tracing process, guide those who have been exposed on what to do next, and prevent onward transmission of a disease, such as COVID-19. 4032 0 obj <> endobj The goals of contact tracing are to: 1. 3 0 obj e Emergency Management Act, 2004. Overall Training Goal After completing all training below, learners should be able to be effective COVID-19 case investigation and contact tracing supervisors or leads. Title: Contact Tracing Form Created Date: Primary Guest oF Guest #2 oF Guest #3 oF Guest #4 oF Have you, or anyone in your party have had the following symptoms? You can use this service to: fill in and submit a passenger locator form before you leave for the UK. Contact Tracing . It may also be found in your contact tracing form or in your contact tracing app—if you’re using one. 10��"� ,�A�lҁa�V�&�U1 The document will also assist in estimating the resources required for conducting contact tracing as well as monitoring performance of affected districts on ensuring properly contact tracing activities. Ideally, health departments should collect information on all close contacts. This information will support contract tracing, if a case of COVID-19 is linked to your business. Identify date of first symptoms � �� 6.a Develop contact tracing protocols. This form can help you identify your contacts so you will be ready for the call. The Trace Team will use the COVID-19 Contact Tracing Forms (Enclosure 3) to interview the positive patient. These guidance notes are based on best practice from extensive field experiences during endobj endstream endobj 4033 0 obj <>/Metadata 155 0 R/Names 4058 0 R/OpenAction 4034 0 R/Outlines 532 0 R/PageLayout/SinglePage/PageMode/UseThumbs/Pages 4024 0 R/StructTreeRoot 621 0 R/Type/Catalog/ViewerPreferences<>>> endobj 4034 0 obj <> endobj 4035 0 obj <. <> may only be used for the purpose of contact tracing in relation to COVID-19. The COVID-19 Contact Tracing Playbook provides actionable technical guidance, including implementation checklists and tools, for each domain of a successful contact tracing program. If seeking a sample training plan, trainings, … This form can be downloaded at www.sa.gov.au V2 as at 1/06/2020 CONTACT TRACING RECORD – ATTENDANCE AT PUBLIC ACTIVITIES *These records must be retained and if requested, be produced to an Authorised Officer as proof of compliance with Directions issued pursuant to the Emergency Management Act, 2004. Do you consent to receive messages via text? Ensure appropriate medical evaluation and care if the contact becomes symptomatic, and 3. VISITOR CONTACT TRACING FORM Please fill up the form below in compliance with DTI and DOLE Interim Guidelines on Workplace Prevention and Control of COVID-19. <>/Metadata 1538 0 R/ViewerPreferences 1539 0 R>> Within 6 … This document is a resource companion to the . Travel Declaration and Contact Tracing Form Lodging Temperature recorded upon check-in. Contact tracing is best undertaken in settings where appropriate, accurate and culturally sensitive communication and messaging exist. *5S9mAKX=�bu�H(� �� c�g^�x��C� ��Ul7�1&8('V\`W;"�Ĥ�P��u@��q�B�f-�f�� &HHP��ܠ�� H�b`�e �3��@Z��1(�3�M2H�d�e`Sև�d4 0 �V Complete the passenger locator form online. h�b```b``�e`e`��ab@ !�ǂC�N-��ă��X_1�r.��a}ð�@@_��́��,Q7|��83�28N`�b��`� V�j�X d�6;��y�� Employers must keep a record of all workers and visitors who attend the workplace for longer than 15 minutes, including first name, contact number, date and time of visit and areas of the workplace visited. Digital tools for COVID-19 contact tracing. <> Please circle relevant choices: Fever or chills Cough Shortness of breath or di˜culty breathing Fatigue Muscle or body aches Your cooperation is greatly appreciated. What contact tracing is. %PDF-1.7 %�� If cases of COVID-19 detected that have a link to a business, NHS Scotland may contact the business by phone to request staff and customers’ details to allow contact tracing to take place. stream (If you do not consent to text, you will be called to clarify any information needed.) ... please contact the NYS COVID-19 Hotline at 1-888-364-3065. �=\�B*E�M�*��x0:�c��+��䠐��g��w��j��;�}(�a�}G^�F��ѬIT�A�!�0��)pL��a��'��-�Jpe�+��0IA��uА��_\�e7>��a�-)eU�V�ʯ$�_��Զ��)h��t禝�Z��n��]ܵ�ح��~��o�ׂ��=PEY��r�@�M�35��ϡi�h��h�,��g��p�Vڿ�5\�e�a��6dz +EY�A�ר��K��j�2t��zP�ksz� $Z,��AV��Cu�+N�V��^6�gH3}�yXj:�ҲɏrƓ��;ǝi|w��&��-7��pr?��.�x�)L�b�:�v۪�l��1�{�/S)��S�_��S@�%��E�OU?Uq:1��,��a 2 0 obj Define person under investigation (PUI), contact, and contact tracing 2. investigation and contact tracing and support the referral of symptomatic contacts to designated isolation and treatment facilities. Describe the objectives of contact tracing 3. The guidance notes are meant to standardize and scale up contact tracing activities in all the affected communities. This document provides updated guidance on how to establish contact tracing capacity for the control of COVID-19, and how to prioritize contact tracing activities in different settings. Contact tracing register — individual ballot entries A page of individual ballot entries that visitors can fill out and put in a ballot box. pursuant. �d"-��Y�ԙ�9��vTH�i��Ca��ܯ�+�4y�F��ԙ��jӦ]UӰ��T��R�\Ȭ �C�pPu�M�R-��"��46�2T0�j��*��K�2�[&"U�ʫ��)A)b�� ... Use of a medical or non-medical mask as a form of source control may limit the spread of respiratory droplets from the case to the contact and into the environment, reducing the With the COVID-19 pandemic getting more and more serious every day, it’s important to support those who’ve been hit the hardest. Food Premises Contact Tracing Form Applies to Food Premises in Green, Yellow or Orange Zone * In Ontario Regulation 364/20: Rules for Areas in Stage 3, the name and contact information of every member of every party that enters an indoor or outdoor dining … Insensitive and inappropriate messaging and practices during outbreaks Restricted use and disclosure: The collection document record can only be used for contact tracing by Public Health officials in case of an outbreak. Contact Tracing Tool for People Being Tested for COVID-19 If you test positive for COVID-19, you will get a call from a public health representative to identify any contacts you have had. Authority on request if it is required for contact tracing purposes. Once a case has been identified, the Ministry of Health and the local district health board's public health unit (PHU) track down people who may have been exposed to the virus through a process called contact tracing. NEW YORK STATE TRAVELER HEALTH FORM rev. Officer as proof of compliance with Directions issued . • Basic Concept of Contact Tracing • How to Conduct Step 1: Contact Identification • How to Conduct Step 2: Contact Notification • How to Conduct Step 3: Contact Follow-up • COVID-19 Resources Once a positive test result is received, the Contact Trace Fusion Cell activates the Trace Team. Contact Tracing Form Date and time of service: Place of service: Name and contact details of organiser: Family name of the deceased: Name: Time IN: Time OUT: Phone number: Email address: Seat number at seated service: COVID —19 MINISTRY OF H MA NAT u I-IAU ORA New Zealand Government . to th. endobj The NHS Test and Protect service has a number of mechanisms in place to reassure people contact tracers are legitimate, including call back options, visible numbers, and specific location and date information. Case study 1: Risks involved in staff handling personal information collected for contact tracing purposes. 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