Clermont County Public Health is using this online tool to collect information from COVID-19 positive patients.  This information helps our nurses to better understand what is happening in our community, identify disease trends, find outbreak clusters, and identify close contacts that may need quarantined. 

Completing this questionnaire helps our nurses keep pace with the increasing number of COVID-19 cases that our community is seeing.

Once this survey is completed, we will call or email you with any questions.  We will also develop a letter that documents that you have been placed in isolation by public health, if we have not done so already.

Information provided in this form is confidential and is for public health use only.

Thank you for your help.

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* First Name

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* Last Name

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* Date of Birth

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* Cell Phone Number

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* Email

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* If the sick person is under age 18, please provide the parent or guardian name.

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* Gender

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* Are you pregnant?

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* Ethnicity

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* Race

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* Address

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