AFED COVID 19 Data collection form

Reason for collection

AFED is collecting this data for the following reasons:

Obtain statistics on the spread of the COVID-19 virus within our region
Facilitate needs assessment and design of a tailored plan to support impacted individuals.
Understand risks to existing members, and provide risk mitigation strategies as needed.

Privacy

The personal information contained in this form will only be shared with your local jamaat support group and the AFED COVID-19 team. The information will be stored in accordance with AFED privacy policies and will be in accordance with legislative requirements in both the Main Land Africa and the Islands of Madagascar, Reunion and Mauritius.

If you would like to provide statistical information, but not provide personal identification information, please complete the form but do not complete the sections that can identify the patient or the family.

Changes

If there is a change in the status of the patient, please do not submit a new form. Please make changes to your submission using the instructions below:

When you submitted the original form, you would have received a confirmation email containing a link to the pre-filled form.
From that link, you can update your entry and change the status of the patient if necessary.

Date of input

Date

Name of person completing form

First Name Last Name

Phone Number of person completing form

Area Code Phone Number

Email of person completing form

example@example.com

Name of patient

First Name Last Name

World Federation Region of patient

Country of patient

Jamaat of patient

Was the patient a member of the jamaat

Patient ethnicity

Has the patient been diagnosed/tested

Date of diagnosis

Date

Date first symptoms seen

Date

Source of virus

Gender

Was the patient a health care worker

Age range

Case status

If case status is active, please indicate patient condition

If case status is closed, please indicate patient condition

Date of death

Date

Death recorded on this form

Date

Income of COVID-19 patient family

Symptoms presented

Yes

No

Fever

Sore throat

Cough

Headache

Respiratory issues

Pre-existing conditions

Yes

No

Heart disease

High blood pressure

Diabetes

Kidney disease

Respiratory sickness

Auto immune disorder

Cancer

AFED Covid-19 Cases Data Collection