COVID-19 Positive Case Survey

The Clinton County Health District is using this online form 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 form online helps our nurses keep pace with 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 the health department. You and your “Close Contacts” will NOT receive release letters if you do not complete this survey.

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

Thank you for your help!

Last Updated 08/12/2021

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* 1. Tell us about yourself

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* 2. What is your date of birth?

Date

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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. What date did your symptoms first begin?

Date

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* 10. Have you been hospitalized?

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

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

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

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* 14. Do you have any preexisting medical conditions?

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* 15. Have you previously received the COVID vaccine?

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

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

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* 18. 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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* 19. Close Work Contacts: People who have had close contact with you 48 hours before you started feeling symptoms up until the present can be at risk for getting sick with Covid-19. It is important that these people are notified that they may have had an exposure to this illness.  This lets us protect high risk people in the community.

Close contacts is defined as being within 6 feet of a person sick with COVID-19 for at least 15 minutes of time in a 24 hour period. This can include short term contact throughout the day if the total time is 15 minutes.

It can be helpful to sit down and write out your daily activities and people you may have seen.

Please include the work contact's name, phone number and email address. If you need more room, you can email a list of your close contacts to covidcontacts@clincohd.com

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* 20. Close Contacts: People who have had close contact with you 48 hours before you started feeling symptoms up until the present can be at risk for getting sick with Covid-19. It is important that these people are notified that they may have had an exposure to this illness. This lets us protect high risk people in the community.

Close contacts is defined as being within 6 feet of a person sick with COVID-19 for at least 15 minutes of time in a 24 hour period. This can include short term contact throughout the day if the total time is 15 minutes.

It can be helpful to sit down and write out your daily activities and people you may have seen.  This list often includes family members, friends and others outside work that you may interact with.

Please include each contact's name, phone number and email.  If you have additional contacts, you can email your list of close contacts to covidcontacts@clincohd.com

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

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