Positive Covid 19 Investigation

Your answers to the questions below will help us to identify, monitor, and track this virus within our county. This interview is secure and confidential. The online process is more timely and effective than phone interviews, but if you have any questions, please contact us at 740-441-2965 or 740-441-2950 during regular business hours 

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* 1. First Name

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* 2. Last Name

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* 3. Date of Birth

Date

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* 4. Telephone Number

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* 5. Email Address

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* 6. Male or Female?

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* 7. Address

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* 8. Have you been vaccinated

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* 9. Are you currently employed?

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* 10. If yes, please enter your place of employment and position

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* 11. Have you notified your employer?

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* 12. Race

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* 13. Ethnicity:

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* 14. Please Check any of the following that apply to you:

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* 15. If you are a school employee or student, please select your school district

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* 16. Do you have any medical or drug allergies?

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* 17. Smoking:

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* 18. Hospitalized?

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* 19. If yes, please list facility

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* 20. Symptomatic?

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* 21. What date did you first become symptomatic?

Date

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* 22. Please check all symptoms that you have experienced recently

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* 23. Please indicate any pre-existing conditions.

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* 24. In the last 14 days, have you traveled to any other areas?

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* 25. Within the last 14 days, Have you attended the following

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* 26. When is the last date you attended work/school?

Date

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* 27. Have you been around anyone who has tested positive?

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* 28. Have you been around anyone who has tested positive?

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* 29. Do you need a work excuse?  (This will be mailed or faxed separately)

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* 30. Please help us inform any Direct Contacts you have had. A direct contact is anyone you have touched (hug, handshake, sports contact) or if you have been closer than 6 feet for a total of 15 minutes or longer over a 24 hour period. If you were both masked or if the contact is fully vaccinated, you don't need to include them.
Please go back to 2 DAYS before your symptoms began. (You can be contagious up to 2 days before symptoms begin) 
Start with your own household and then consider friends, co workers, team members, etc. 
Please list Name, Relationship, Phone Number, and Date of Last Contact

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* 31. Education -- Please Read:
Please stay in your own space and do not travel unless it is medically necessary.
Household members should stay in another room or be separated from the patient as much as possible.
Household members should use a separate bedroom and bathroom, if available.
Prohibit visitors who do not have an essential need to be in the home. Household members should care for any pets in the home. Do not handle pets or other animals while sick.
Make sure that shared spaces in the home have good air flow, such as by an air conditioner or an opened window, weather permitting.
Perform hand hygiene frequently. 
Avoid touching your eyes, nose, and mouth with unwashed hands.
Avoid sharing household items with the patient. 
Clean all “high-touch” surfaces, such as counters, tabletops, doorknobs, bathroom fixtures, toilets, phones, keyboards, tablets, and bedside tables, every day. Also, clean any surfaces that may have blood, stool, or body fluids on them. Use a household cleaning spray or wipe, according to the label instructions. Labels contain instructions for safe and effective use of the cleaning product including precautions you should take when applying the product, such as wearing gloves and making sure you have good ventilation during use of the product.
If, after 5 days from first symptoms or positive Covid test, you have no symptoms, you may resume normal activities. You should wear a mask for 5 more days to reduce any likelihood of any remaining virus affecting others.

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