Section 1: Patient information (All fields in this section must be filled in)

1.6 Age

Age (years)

Age (months)

1.8.1 If health facility, name of health facility: GERTRUDE’S CHILDREN’S HOSPITAL

Contact Person: Dr. THOMAS NGWIRI 0733 753 650 Email:TNGWIRI@GERTIES.ORG

Email results to:Dr. BEATRICE KABERA 0721 203 153 Email: BKABERA@GERTIES.ORG

Section 2: Clinical information

Patient clinical course

Patient signs

2.5 Temperature
℃

Section 3: Exposure and travel information in the 14 days prior to symptom onset (prior to reporting if asymptomatic)

Section 4: Laboratory Information

Specimen collection (To be completed by the health facility)

(To be completed by the laboratory confirming the test)