JB MDL Version 6, 05 May 2020
COCOM:
Service:
Installation:
Age:
Rank:
Notes / Comments:
Major Command/Organization:
Date Reported:
Yes No
Is the Patient a Medical Staff Member?
Did the Patient Travel OCONUS w/in the Last 14 Days?
Did the Patient Travel CONUS w/in the Last 14 Days?
Is the Patient Isolated?
Was the Patient Hospitalized?
If Patient was Hospitalized, are they still?
Hospitalized? Did the Patient Require ICU Care?
Did the Patient Require a Ventilator?
Is the Patient in Self-Quarantine?
Has the Patient Recovered?
Is the Patient Deceased?
Reporting Template - COVID-19 Positive Test Results
Echelon:
General Information
Personnel Information
Individual Name:
Contact Number:
Answer the Following
Where:
Where:
Where:
Where:
Point of Contact Information
Contact Number:
Rank / Name: Unit / Agency:
Email:
Individual Status:
Sex:
Is the Individual Asymptomatic?
If No Select Option:
Testing Conducted: Date Tested Positive:
AFSC/MOS:
Deployed ISO COVID-19 Operations?
DOD ID #:
Country: State:
