Enter Your First Name
Enter Your Last Name
Select your Gender
Enter Your Age
Select Your Nationality
Enter Your residence (optional)
choose Your subcity
Enter woreda (optional)
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Enter House number (optional)
GPs (for house collection) optional
Enter your phone number
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Enter your email
Enter Passport number (if you are a traveller)

  Health care worker
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Enter Your occupational region (optional)
Enter Occupational sub-city Select unknown to skip
Occupational Woreda (optional)
Where do you work
  Yes   No

  Cough
  Fever
  Shortness of breath
  Sore throat
  Headache
  Easy fatigue
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  Diabetes Mellitus
  Hyper Tension
  HIV
  Chronic Respiratory Disease
  Chronic Cardiac disease
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  Other
  Yes   No

  Suspect
  Contact of confirmed case
  Discharge from quarantine purpose
  Community surveillance
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  New
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  Follow up I
  Follow up II
  Follow up III
  Travel purpose