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).
Name
*
First Name
Last Name
Email
*
example@example.com
Mobile number
*
Designation
*
Faculty
Admin staff
Research sssistant (URA or Project-based)
Graduate student
Undergraduate student
Custodian/ Janitor
Guard
Lab Aide
Intern (CIP, etc)
Other
Which laboratory or office are you affiliated with?
*
Admin Office (also for students without any lab affiliation)
ABL
DMBEL
FGL
LMCB
MEL
MTRL
NBL
PSIL- DMB
PSIL- NADB
PIGGL
PMBPVL
SML
What is your reason for filling out this form?
*
I HAVE COVID-19 SYMPTOMS and confirmed to be COVID-19 positive by RT-PCR or rapid antigen test (RAT).
I HAVE NO COVID-19 SYMPTOMS but confirmed to be COVID-19 positive by RT-PCR or RAT.
I am EXPERIENCING COVID-19 SYMPTOMS but have NOT been tested for COVID-19.
I am a CLOSE CONTACT of a confirmed COVID-19 positive case.
What is your vaccination status?
*
Partially vaccinated (received one of two vaccine doses)
Fully vaccinated
Fully vaccinated with booster shot
Where are you currently residing?
*
Family residence
Boarding house
Dormitory
Shared condo/ apartment
Other
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Details of COVID-19 Symptoms
When did you first experience COVID-19 symptoms?
-
Month
-
Day
Year
Date
What COVID-19 test did you take?
RT-PCR- nasal/pharyngeal swab
RT-PCR- saliva
Rapid antigen test- nasal/pharyngeal swab
Rapid antigen test- saliva
I have not taken any test
If you took a COVID-19 test, when was your swab or saliva sample taken?
-
Month
-
Day
Year
Date
Which of the following symptoms have you experienced in the past 7 days? Check all that apply.
Fever
Cough and/or colds
Body pains
Sore throat
Fatigue/ tirednes
Headache
Diarrhea
Lost of taste or smell
Shortness of breath
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Asymptomatic and confirmed to be COVID-19 positive
What COVID-19 test did you take?
RT-PCR- nasal/ pharyngeal swab
RT-PCR- saliva
Rapid antigen test- nasal/pharyngeal swab
Rapid antigen test-n saliva
When was your swab or saliva sample taken?
-
Month
-
Day
Year
Date
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Close contact of a confirmed COVID-19 positive case
When was your last contact with a confirmed COVID-19 positive case?
-
Month
-
Day
Year
Date
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Other information
When did you last enter NIMBB?
*
-
Month
-
Day
Year
Date
Which of the following facilities/rooms/labs did you access the last time you were in NIMBB? Check all that apply.
*
1F- admin office
1F- bathroom
1F- classroom
1F hairpin loop dining area
2F- Rm 201/202/203
2F- Rm 206
2F- MEL
2F- ABL
2F- PMBPVL
2F- MDIC
2F- bathroom
2F- faculty room
2F- DSCF
3F- bathroom
3F- RA station
3F- faculty room
3F- central lab
List down the names of your close contacts the last time you were in NIMBB. Put "NA" if you had no close contact during your last visit to NIMBB.
*
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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.
Submit
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