• Fields marked with asterisk (*) are mandatory to be filled

• *Repeat Sample: YES NO
• If Yes, Patient ID:

• *Patient Name:
• DOB:
• *Patient in quarantine facility: YES NO
• Gender: Male Female Other
• *Present Village or Town:
• *Mobile Number:
• *District of Present Residence:
• Mobile Number belongs to : Self Family
• *Present patient address:
• Nationality:
• *Pincode:
• Download Aarogya Setu app: Yes No

  (These fields to be filled for all patients including foreigners)

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• *Email:
• Passport No. (For Foreign Nationals):
• * Aadhar No.(For indians) :
  
• Father Name/ Husband Name (As
  mentioned in aadhar Card

• Collection Date :
• Sample Collection By :
• Sample ID (Label):
• Sample Collector’s Phone No. :

A.4.1 Routine surveillance in containment zones and screening at points of entry

• Cat 1: All symptomatic (ILI symptoms) cases including health care workers and frontline workers:
• Cat 2: All asymptomatic direct and high-risk contacts (contacts in family and workplace, elderly ≥ 65 years of age, those with comorbidities etc.:
• Cat 3: All asymptomatic high-risk individuals:

A.4.2 Routine surveillance in non-containment areas

• Cat 4: All symptomatic (ILI symptoms) individuals with history of international travel in the last 14 days:
• Cat 5: All symptomatic (ILI symptoms) contacts of a laboratory confirmed case:
• Cat 6: All symptomatic (ILI sym ptoms) health care workers / frontline workers involved in containment and mitigation activities:
• Cat 7: All symptomatic ILI cases among returnees and migrants within 7 days of illness:
• Cat 8: All asymptomatic high-risk contacts (contacts in family and workplace, elderly ≥ 65 years of age, those with co-morbidities etc.:

A.4.3 In Hospital Settings

• Cat 9: All patients of Severe Acute Respiratory Infection (SARI):
• Cat 10: All symptomatic (ILI symptoms) patients presenting in a healthcare setting:
• Cat 11: Asymptomatic high-risk patients who are hospitalized or seeking immediate hospitalization:
• Cat 12: Asymptomatic patients undergoing surgical / non-surgical invasive procedures (not to be tested more than once a week during hospital stay):
• Cat 13 : All pregnant women in/near labour who are hospitalized for delivery:
• Cat 14: All symptomatic neonates presenting with acute respiratory / sepsis like illness:
• Cat 15 :Patients presenting with atypical manifestations [stroke, encephalitis, hemoptysis, pulmonary embolism, acute coronary symptoms, Guillain Barre syndrome, Multiple Organ Dysfunction Syndrome,progressive gastrointestinal symptoms, Kawasaki Disease (in pediatric age group)]based on the discretion of the treating physician:

A.4.4 Testing on demand

• Cat 16: All individuals undertaking travel to countries/Indian states mandating a negative COVID-19 test at point of entry:
• Cat 17: All individuals who wish to get themselves tested:
• Other: (please specify) * (Select “other" only if the patient doesn’t belong to category 1-17):