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Coronavirus Case Report Survey Form
Please fill out the form
Reporter Name:
First Name
Last Name
This field is required.Please enter value
This field is required.Please enter value
Reporter Mobile No:
This field is required.Please enter value
Invalid phone number.
The value must be less than or equal to 20
Email Id:
This field is required.Please enter value
Please enter valid email address
Reported Name:
First Name
Last Name
This field is required.Please enter value
This field is required.Please enter value
Reported Mobile No:
This field is required.Please enter value
Invalid phone number.
The value must be less than or equal to 20
Report Date & Time:
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Date format is invalid, please check it again
The value must be greater than or equal to -21474836487
The value must be less than or equal to 2147483647
When did you first suspected:
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Date format is invalid, please check it again
The value must be greater than or equal to -21474836487
The value must be less than or equal to 2147483647
Email Id:
This field is required.Please enter value
Please enter valid email address
Why are you reporting this person:
Coughing
Fever
Having shortness of breath
Feeling persistent pain or pressure in the chest
Having confusion or inability to arouse
Just came from abroad, carrying highly risk of COVID-19
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Additional Comments:
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Submit
