Clinics: Free Digital Covid-19 Contact Tracing Form

You are an essential service. Let us help make your life easier. 

Setting things up takes just a few minutes, and no technical knowledge,  with the step-by-step guide below. But, if you really need help contact us here.

Please note, this form is a legal requirement in many countries, with severe penalties for non-compliance. As an example, please refer to clauses 10B (b) & (c) for Singapore on the following link from Singapore Statutes Online. 

 

https://sso.agc.gov.sg/SL-Supp/S262-2020/Published/20200410?DocDate=20200410​

We are providing these Digital Covid-19 Contact Tracing Forms for you to use for FREE, at our own expense, as you need to do so. Please refer to the FAQs at the bottom of this page to answer all your questions about data ownership, PDPA, GDPR, data access, data deletion, etcetera. As a summary, it all belongs to you. 

Stop Spreading The Virus By Forcing People To Fill Up Paper & Pen Based Contact Forms.

Go Digital.

Get People To Scan QR Code / Type In URL On Their Your Own Device, Fill Up Details And Walk In.

No Need To Be A Computer Programmer To Set It Up Or To Download Any App To Use It.

Set It Up In A Few Minutes. Just Scan QR Code Or Type In Url Into Browser To Use It.

YOUR COVID-19 CONTACT TRACING FORM WILL INSTANTLY DIGITISE AND TIMESTAMP YOUR:

1) Patients' contact data at your various locations and touchpoints. This includes their body temperature, travel and health declaration.

2) Staff attendance along with their body temperature data, as many times as required.

3) Visitor registration information, so you know who was on your premises and when. 

USE YOUR DIGITISED COVID-19 CONTACT TRACING DATA TO:

1) Build consumer confidence and have people feel safe on your premises by communicating you are a socially responsible organisation.

2) Help your health authorities with the relevant digitised Covid-19 Contact Tracing Data for their Covid-19 Contact Identification, Contact Listing and Contact Follow Up purposes. 

3) Interrupt the transmission of the Covid-19 Virus and reduce the rate of infection. 

Quick Step-By-Step Set Up Guide

STEP 1 - Sign Up

Create a new account at

https://default.cusjo.com/signup

then follow the instructions till you get to the "Select Survey Template" page.

STEP 2 - Select Template

On the "Select Survey Template" page type in, "Clinic" into the search box. Then click on the "Dental Clinic Covid 19" or "Medical Clinic Covid 19" Form as appropriate.

STEP 3 - Build

You will now be at "Template Preview". Click on the "Build" button to its right. This is where you can edit the questions, but only if you need to. Then click, the "Save" button under the "Build" button. You will see "Theme""Preview""Publish" and "Analyse" turn up to the right of it.

STEP 4 - Publish

Click on "Publish". Type in "Covid" in the box to the left of "Save" then click "Save". next click "Publish Survey". A pop up box will ask for a confirmation. Click "Ok" on the pop up box. Your QR Code and URL will appear below the "Publish Survey" button. 

STEP 5 - Print

Right click on the QR Code and "save image as". Your QR Code image should now be in your Download folders. Go to any document (MS Word, Google Docs, Apple Pages or MS Powerpoint, Google Slides, Apple Keynote), copy the words below, add in your QR Code from your download folder, and add in your URL from the "Publish" Page. Print out your poster and display it prominently wherever you need contact data to be collected. 

 

​Here is the text to copy, paste and print.

Your Well-Being Is Our #1 Priority.

Please complete our Contact Tracing form before entering our premises.

{Add in QR Code and URL here}

It will take less than 30 seconds and will make you feel a lot more comfortable too. Thank you!

STEP 6 - Submit

Get your patients to either scan the QR code on their smartphones (apple / android) or type in the URL in their browsers, so they can "Submit" the form on their own device without having to even touch any common device. 

STEP 7 - Analyse

Once they click "Submit" you will get instantaneously digitised time stamped data, to access in case of an emergency. No more cumbersome paper-based process and data entry required. Go to "Analyse" on your domain (e.g. YOURCOMPANY.cusjo.com) then click on "Response". You can also export your data by clicking on "Export" and then "Excel".

Example of Covid-19 Contact Tracing Form

You can customise this form to suit your Business-to-Business, Business-to-Consumer, Government-to-Citizens, religious, social and private group purposes. 

Scan QR Code or click on a link to see demo. 

 

https://amosclinic.cusjo.com/covid

This Is How It Works From Your Patients', Staffs' & Visitors' Point Of View

Easy, Fast & Efficient.

1. Your patient arrives, and sees your poster.

2. Your patient uses his/her own smart phone to scan QR code or type in URL.

3. Your patient fills up the form, clicks submit and walks in.

Frequently Asked Questions

1) Is the Covid-19 Contact Tracing Form free and for how long is it free?

It is completely free, there are no strings attached. And it is for you to use as long as you want or need to. 

2) Is my data mine and secure?

Yes, the data is solely yours, accessible by your appointed administrator who has a username and password. You can download the data and delete it from your https secured company specific domain at any time. It is recommended you keep the data there for 90 days and delete any data that is more than 90 days long. You can do this on your Response page under the Analyse tab. As a word of warning, once you delete the data, it will be removed from our servers in 24 hours and we will not be able to recover it for you. You are welcome to download your data onto an excel sheet before you delete it, if you feel you need it. 

3) Can I upload my own Personal Data Protection Act (PDPA) and General Data Protection Regulation (GDPR) policies?

We have already uploaded a Terms and Conditions message for you at the bottom of the Submit button. Having said that, everything on the form is editable. So, you can copy and paste your own internal organisation policies in the disclaimer either just above or below the Submit button as per your local data laws.

4) How do I ensure everyone who engages with my organisation fills in their details?

Once you have created your account, launched your form and published your URL and QR Code, you can then put them up at all entry points to either get people to fill it in on the spot or in advance, as appropriate. Once they complete a form, on refreshing the Response page under the Analyse tab, you will be able to see their response come in  live. Once you see their contact details there you can read them. If they meet your criteria, you can safely let them into your premise.  

5) How do I use my Covid-19 Contact Tracing Form to help local and international health authorities?

In the event someone who visited your location was asymptomatic at the time of their visit and subsequently symptomatic, you can identify all the individuals who were in contact with this person on your excel sheet or on your Response page. You can then seek the assistance of your local and international health authorities to contact, alert and quarantine the individuals who were there that day, to prevent further transmission. 

 

6) Can I use my Covid-19 Contact Tracing Form across any social media and communication platform?

Yes. You can also put it on posters, embed it into your website, mobile apps, social media channels, into videos, intranet or anywhere necessary. All you need to do is copy and paste your URL and prominently put up your QR Codes with your call to action message. 

7) Can the Covid-19 Contact Tracing Form be used anywhere in the world?

Yes. Including China. We are not barred by any country's firewalls as far as we are aware.

8) Can I use this for non B2B and B2C purposes?

You can modify the form for any purpose you like. It can be used for religious, social and private gatherings. Basically anywhere where people meet and want to be safe rather than sorry.

9) Can this be translated into other languages other that English?

We are in 106 languages. The default language is English. If you need it translated into any other language please contact us. We will need to enable our realtime AI translation and assist you. Please note outside of this and the next question, the form and platform is designed to be self-served.

10) What if I am a large global organisation with multiple branches in one country or touchpoints around the world?

This free version can still serve your needs. Create a drop down and upload all your branches, touchpoints or international locations on it. Then your visitors can pick the location they are at as they fill in the form. If you however need different people at different locations to administer the data you will need to contact us. We will have to assist you create multiple touchpoints in line with your global hierarchy and associate a unique log in  for each touchpoint for your staff. This will be to ensure the relevant data is only shared with the relevant people in each country and touchpoint. 

11) What size of groups can I use the Covid-19 Contact Tracing Form for?

You can use the form for groups as small as 5 people in a very private meeting or 5000 people at a conference or event. Also, since this is an ongoing effort, you can let you list build and delete once the data is there for longer than 90 days old, or earlier if you choose to do so. 

12) Who are you doing this on behalf of?

This is a ground up effort to assist and we are doing it for free. We decided to do this when:

 

a) we were alerted to the fact that the government advisory for organisations was to, as practical, maintain a registration list, carry out temperature screening, look out for Covid-19 symptoms, deny entry to unwell individuals, track travel history and make a health declaration, and,

b) when we realised most organisations did not have a fast, effective and digitised method to assist in contact tracing efficiently, and to build one would be too costly and take too long.

13) What are some things that are critical for this to work?

Companies need to be honourable and not use the data for any other  purpose other than contact tracing, or trust will be broken and never repaired. People need to give accurate data or they will put themselves and loved ones at risk.

About CusJo

Serving clients globally via representatives in  21 countries, CusJo helps enterprises get real-time experience management benchmarks through surveys. We assist you confidently innovate your employee, customer, product, brand and market experience on the world's most innovative enterprise survey platform - loved by our customers and you.

We're unique because our Software-as-a-Service (SaaS) platform:

a) Has the world’s 1st AI Consensus Engine (ACE), which does 3 months worth of  qualitative data analysis in a few seconds.

b) Provides you with more than 150 customisable professional templates to get started immediately.

c) Is available in 106 languages, so you can engage your audience globally and use our AI engine to do real-time translations.

d) Allows you to map and benchmark employee, customer and market research experience in realtime and get automated AI reports.

You can also use our ACE for your live QnA sessions at your town halls, meetings, conferences, conventions and even national conversations. Never again will your audience have to vote questions and answers up or down, as our ACE will do it in real-time for you.

So, contact us through any one of the countries below, to customise an experience management survey solution, regardless of where in the world you are.

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