NIMBB COVID-19 Case Report Form

  • NIMBB COVID-19 Case Report Form

    Fill up this form if you are experiencing any COVID-19 symptoms, confirmed to be COVID-19 positive by RT-PCR or rapid antigen test, or a close contact of a confirmed COVID-19 positive case. For urgent concerns, please get in touch with the NIMBB Health Liaison Officer Mark Fran (09178180428).
  • Designation*
  • Which laboratory or office are you affiliated with?*
  • What is your reason for filling out this form?*
  • What is your vaccination status?*
  • Where are you currently residing?*

  • Details of COVID-19 Symptoms

  • When did you first experience COVID-19 symptoms?
     - -
  • What COVID-19 test did you take?
  • If you took a COVID-19 test, when was your swab or saliva sample taken?
     - -
  • Which of the following symptoms have you experienced in the past 7 days? Check all that apply.

  • Asymptomatic and confirmed to be COVID-19 positive

  • What COVID-19 test did you take?
  • When was your swab or saliva sample taken?
     - -

  • Close contact of a confirmed COVID-19 positive case

  • When was your last contact with a confirmed COVID-19 positive case?
     - -

  • Other information

  • When did you last enter NIMBB?*
     - -
  • Which of the following facilities/rooms/labs did you access the last time you were in NIMBB? Check all that apply.*

  • Submit your response

    By clicking the submit button, I hereby certify that the information given is true, correct and complete. I understand that failure to answer any question or any falsified response may have serious consequences under RA 11332 or the Law on Reporting of Communicable Diseases. I also recognize that any personal information given in this form is protected by RA 10173 or the Data Privacy Act of 2012.
  • Should be Empty: