Covid-19 Investigation

Your answers to the questions below will help us to monitor and track those who have been exposed to a positive Covid-19 case. This interview is secure and confidential. This 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 that you have been exposed?

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* 12. Race

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* 13. Ethnicity:

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

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

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* 16. Smoking:

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* 17. Are you pregnant?

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* 18. Symptomatic?

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* 19. Please check any symptoms that you have experienced recently

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* 20. Please indicate any pre-existing conditions.

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* 21. Have you been around anyone else that you know is positive?

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

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* 23. You may receive text messages from Ohio Department of Health to monitor symptoms. If you would prefer phone calls, please indicate below.

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* 24. 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. Wash your hands often with soap and water for at least 20 seconds or use an alcohol-based hand sanitizer that contains 60 to 95% alcohol, covering all surfaces of your hands and rubbing them together until they feel dry. Soap and water should be used preferentially if hands are visibly dirty.
Avoid touching your eyes, nose, and mouth with unwashed hands.
Avoid sharing household items with the patient. Do not share dishes, drinking glasses, cups, eating utensils, towels, bedding, or other items. After the patient uses these items, you should wash them thoroughly in warm or hot water and dry on highest dryer setting permittable for the fabric.
Avoid shaking out laundry.
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.

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