Clinton County Health District

COVID-19 Positive Case Survey

The Clinton County Health District (CCHD) is using this online form to collect information from COVID-19 positive individuals. This information helps our team to better understand what is happening in our community, identify disease trends, and find outbreak clusters. Completing this form online helps us keep pace with increasing number of COVID-19 cases that our community is seeing and focus our response efforts on vaccinations. Information provided in this form is confidential and is for health department use only.

NOTE: Those individuals testing positive for COVID-19 should use the documents provided by your medical provider/testing facility regarding your positive test results as notice to your employer/child’s school.

Effective December 28, 2021, CCHD will no longer provide Isolation/Quarantine documentation due to delays in reporting of positive test results to the CCHD and the shortened Isolation/Quarantine duration.

Effective December 27, 2021, the Centers for Disease Control and Prevention (CDC) has modified their Isolation and Quarantine Guidance given what is currently known about the Omicron variant as follows:

If You Test Positive for COVID-19 (Isolate)

Everyone, regardless of vaccination status.

·         Stay home for 5 days.

·         If you have no symptoms or your symptoms are resolving after 5 days, you can leave your house.

·         Continue to wear a mask around others for 5 additional days.

If you have a fever, continue to stay home until your fever resolves.

If You Were Exposed to Someone with COVID-19 (Quarantine)

If you:

Have been boosted
OR
Completed the primary series of Pfizer or Moderna vaccine within the last 6 months
OR
Completed the primary series of J&J vaccine within the last 2 months

·         Wear a mask around others for 10 days.

·         Test on day 5, if possible.

If you develop symptoms get a test and stay home.

If you:

Completed the primary series of Pfizer or Moderna vaccine over 6 months ago and are not boosted
OR
Completed the primary series of J&J over 2 months ago and are not boosted
OR
Are unvaccinated

·         Stay home for 5 days. After that continue to wear a mask around others for 5 additional days.

·         If you can’t quarantine you must wear a mask for 10 days.

·         Test on day 5 if possible.

If you develop symptoms get a test and stay home

The link to the CDC Guidance is here: https://www.cdc.gov/media/releases/2021/s1227-isolation-quarantine-guidance.html
Thank you for your help!

Last Updated 12/28/2021

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* 1. Tell us about yourself

Name *

Address *

City/Town *

State/Province

ZIP/Postal Code *

Email Address *

Phone Number *

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* 2. What is your date of birth?

Date / Time

Date

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* 3. Gender

Male

Female

Other (please specify)

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* 4. What is your race?

White or Caucasian

Black or African American

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Other (please specify)

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* 5. What is your ethnicity?

Hispanic or Latino

Non-Hispanic or Non-Latino

Unknown

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* 6. Do you work, live or attend any of the following locations or occupations?

Healthcare settings (hospital, EMS, etc)

Correctional Facilities (jail or prison)

Long Term Care Facility (nursing home, residential home, rehabilitation home)

Preschool or K-12 School

I do not live, work or attend any of the following locations or occupations.

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* 7. If yes, what is your job title and where do you work?

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* 8. Did you use an at home test kit?

Yes

If yes, enter date tested below

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* 9. If you completed a home test, what date was it completed?

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* 10. What date did your symptoms first begin?

Date / Time

Date

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* 11. Have you been hospitalized?

Yes

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* 12. If yes, were you admitted to the Intensive Care Unit?

Yes

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* 13. If you have symptoms, have they gotten better? If so, when?

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* 14. What symptoms have you experienced while sick? Check all that apply

Fever (over 100.4 F)

Subjective Fever (not measured but felt like you had one)

Chills

Rigors

Muscle Aches

Runny Nose

Sore Throat

Cough

Wheezing

Shortness of Breath

Chest pain

Nausea/Vomitting

Headache

Abdominal Pain

Diarrhea

Loss of taste and/or smell

Difficulty breathing

Eye Inflammation

Change in mental status or confusion

Persistant pain or pressure in chest

Inability to wake or stay awake

None- I am asymptomatic

Other (please specify)

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* 15. Do you have any preexisting medical conditions?

Chronic Lung Disease (Asthma/Emphysema/COPD)

Type 1 Diabetes Mellitus

Type 2 Diabetes Mellitus

Obesity (BMI >=30)

Severe Obesity (BMI >=40)

Chronic Kidney Failure

Chronic Liver Disease

Cancer

If female, pregnant

Sickle Cell Disease

Asthma (moderate to severe)

Cerebravascular disease (affects blood vessels and blood supply to brain)

Cystic Fibrosis

Pulmonary Fibrosis (damaged or scarred lung tissues)

Thalassemia (a type of blood disorder)

Immunocompromised state (weakened immune system)
from blood or bone marrow transplant, immune deficiencies,
HIV, use of corticosteroids or other immune weakening medications

Immunocompromised state (weakened immune system) from solid organ transplant

Autoimmune condition

Disability

Psychological/psychiatric condition

Neurologic/neurodevelopmental

Other chronic disease

Current Smoker

Former Smoker

Substance abuse or misuse

Other underlying condition or risk behavior

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* 16. Have you previously received the COVID vaccine?

Yes

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* 17. If you received the COVID vaccine which vaccine did you receive?

Moderna

Pfizer

Johnson&Johnson

Did you receive your booster?

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* 18. In the 14 days prior to illness onset, did you have any of the following exposures (check all that apply):

International Travel

Domestic Travel

Cruiseship or Other Vessel as Passenger or Crew Member

Workplace

Airport/Airplane

Household Contact

Community Contact

Healthcare-associated contact (patient/visitor/healthcare worker) with known COVID-19 case

Animal with confirmed or suspected COVID-19

Adult congregate living facility (nursing/assisted living/long-term care facility)

School/university/child care center

Correctional facility

Community event/mass gathering

Camp

Gym/Fitness centers

Healthcare setting (outpatient)

Hospital

Hotel/motel

Pyschiatric/Behavioral Health Facility

Rehab facility

Religious facility

Restaurant/Bar

Shopping (retail)

Sports team (including those affiliated with school settings)

Unknown

Clinton County Health District

COVID-19 Positive Case Survey

Question Title

* 1. Tell us about yourself

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* 2. What is your date of birth?

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* 3. Gender

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* 4. What is your race?

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* 5. What is your ethnicity?

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* 6. Do you work, live or attend any of the following locations or occupations?

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* 7. If yes, what is your job title and where do you work?

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* 8. Did you use an at home test kit?

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* 9. If you completed a home test, what date was it completed?

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* 10. What date did your symptoms first begin?

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* 11. Have you been hospitalized?

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* 12. If yes, were you admitted to the Intensive Care Unit?

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* 13. If you have symptoms, have they gotten better? If so, when?

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* 14. What symptoms have you experienced while sick? Check all that apply

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* 15. Do you have any preexisting medical conditions?

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* 16. Have you previously received the COVID vaccine?

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* 17. If you received the COVID vaccine which vaccine did you receive?

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* 18. In the 14 days prior to illness onset, did you have any of the following exposures (check all that apply):

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* 19. Have you recently travelled in outside the US? If so, please list destination and how you arrived (plane, cruise ship, etc) If not, please skip

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* 20. Does anyone in your household attend school? If so, please provide the name of the school or district