4 - Locations Form -- Complete for all persons for whom 2019-nCoV testing is being considered
Revised 3/3/2020 at 1:03 pm

Identified Contacts (use additional sheets as needed):

 

 

 

 

 

 

 

 

 

  

 

 
   
 

 
   
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

l: Person #1 Person #2 Person Person #4 Person #5
First and last
name E-
DOB/age 
Sex 15H hill? 15 or?? W: Fen/tags be my; mb 
Re'a?m?Sh'P t? mZ?S??c??ch?EJ' 3523333323?" 6?4 EZZli?c??reme' B?i?i?c??re?rkefr 33332??
case DWorkpiace DWorkplece DWorkpiace Workplace El orkplace
DPublic exposure DPubllc exposure DPubiic exposure Public exposure gimme exposure
DTravel to endemic area DTravei to endemic area DTravet to endemic area DTraveI to endemic area: Travel to endemic area
DPlane DPlane DPlane DPlane DPtane
DOlher transit DOther transit ?fOther transit thtn?j EIOther transit ElOtiler transit
DOlher. DOihec UOther. ?5 car DOther: EiOther.
Phone Home: Home: Home: Home: - Home:
Work: Work: Work: Work: Work:
Cell: Cell: Cell: UAW Cell: Cell: UAWWM
Email Email: Email: Email Email: mhMom?ud
ot- mind as by
Address (City, ML
State, Zip, 5?1 mown
Count TESS 
Date of last l?t 0; Kit/Lo 9} ?2:122 15/91/22 
exposure
Type of contact household ,ctuc hemmed mm (a old-i UL wbtioe made,
with?! Carl membr/ um
emu.
Nature of - a}
contact . gged??e Wig?"
proximity) wow I an a?
Duration of El<1 Hour Hour <1 Hour <1 Hour <1 Hour 
contact DSeveral hours DSeveral hours Several hours Several hours Several hours ?h
[:IEntire day DEntlre day Entire day DEntire day DEntire day
Multiple days Multiple days [:lMultipie days EIMultiple days DMulti is da 3
Is contact Yes?No DUnk DYes mic DUnk DYes [:lNo MUnk DYes No [jUnk DYes DNC I ignk
Onset a e: Onset date: Onset date: Onset ate: Onset date:

None glone DNone MNone DNone
Fever Fever DFever DFever DFever
Temp: Temp: Temp: Temp: Temp: 
[:lFelt feveris [:lFelt feverish DFelt feverish DFelt feverish EIFeit feveris
DCough DCough DCough DCough [:lCough
DSore throat DSore throat DSore throat [:ISore throat DSore throat
DSOB - USOB DSOB - DSOB EISOB
DOther: DOther: DOther: DOther: DOther:
Placed watch unmoun 
??93 FYI WW Korea 91 1 Danish case's boss 59.3%an
ehqs Minot-c; 3?0 a exch come. we?
omit asthma . 5W . lut?lh a warm
Mum cm twath I 1106de in on ai-
?S?X?lb (5855 house an bx] (woe. loyal/y
25 . 
9023? m0. situated du?i . T1314 349,, SWV 
the mom \lw'n r0 so new.
but swim dumq new . se
3? Li 0? Wm - 
(mi 
W?l 00?? .Thmq are memo-
ewmed 9 
l3 Denmag; 
were Sc
,m 1% cm umv 
Entered on: Entered by: CDDB: WDRS: 
Demo 7 AF 4