Infectious Disease Contact Log Form
Log contact tracing information related to an infectious disease case. Please fill out all sections accurately for effective tracing.
Case Reference (if applicable)
Your Full Name
*
First Name
Last Name
Contact Person's Full Name
*
First Name
Last Name
Contact Person's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Contact
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Location of Contact
*
Type of Contact
*
Household
Workplace
Social Gathering
Healthcare Setting
Other
Duration of Contact (minutes)
*
Did the contact person show any symptoms?
*
No
Yes
Unknown
Notes or Follow-Up Actions
Submit Log
Should be Empty: