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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