NCDC COVID-19 TEST REPORTING

NCDC Covid-19 Test Request Request for Covid-19 Testing Online
Resources NCDC Covid-19 Microsite

COVID-19 Rapid Testing

Self Reporting Form

Note: Complete all required fields to avoid delays in processing.

Fields marked * are required

Test sample collection

Sample Collection Center:*

RAPID TESTING LOCATION

Person Identification Information

Firstname(s):*

Surname:*

Sex:*

Male

Female

Date of birth:
(YEAR/MONTH/DAY)

/ /

(If date of birth is unknown, Age will be required)

Age (Years, Months):*

Years, Months Days

Telephone number (Mobile):*

Email:

Address of Residence:*

Address:*

State of residence:*

LGA of residence:*

Ward of residence:

Village/Landmark:

Country of residence:

Person symptoms (from disease onset)*

Ask the suspected case about each of the following symptoms within the last 2 weeks.

Fever (≥38 °C) or history of fever:*

Yes

Unknown

Sore throat:*

Yes

Unknown

Runny nose:*

Yes

Unknown

Cough:*

Yes

Unknown

Shortness of Breath:*

Yes

Unknown

Vomiting:*

Yes

Unknown

Nausea:*

Yes

Unknown

Diarrhea:*

Yes

Unknown

Tiredness:*

Yes

Unknown

Chest pains:*

Yes

Unknown

Red eyes:*

Yes

Unknown

Loss of taste:*

Yes

Unknown

Loss of smell:*

Yes

Unknown

Headache:*

Yes

Unknown

Any other symptom:*

Yes

Unknown

Date of first symptom onset:
(dd/mm/yyyy)

Previous Covid-19 test

Have you taken Covid-19 test before?:*

Yes

Human exposures in the 14 days before illness onset

Have returned from local travel within the last 14 days?:*

Yes

Unknown

Have returned from international travel within the last 14 days?:*

Yes

Unknown

In the past 14 days, have you had contact with anyone with suspected or confirmed COVID-19 (corona/coronavirus)?:*

Yes

Unknown

In the past 14 days, have you attended any event?:*

Yes

Unknown

Have you visited or been admitted to any inpatient health facility?:*

Yes

Unknown

Have you visited any outpatient treatment facility?:*

Yes

Unknown

Have you visited any traditional healer?:*

Yes

Unknown

Person occupation (specify location/facility):*

Level of Education:*

Vaccination Status

Vaccination Status:*

Vaccinated

Unvaccinated

Unknown

Submit

Nigeria Centre for Disease Control

Plot 801, Ebitu Ukiwe Street, Jabi, Abuja, Nigeria
6232 (Toll-Free Call Centre)
[email protected]

Quick Links

NCDC Official Website
NCDC Covid19 Microsite