Positive Covid19 Home Test Interview

Positive Covid 19 Home Test

Please utilize this survey to report a positive home test for COVID-19. 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.

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* 1. Did you test positive on a COVID-19 home test?

Yes

If yes, what date did you test positive? (MM/DD/YY)

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* 2. First Name

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* 3. Last Name

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* 4. Date of Birth

(MM/DD/YYYY)

Date

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* 5. Telephone Number

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* 6. Email Address

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* 7. Male or Female?

Male

Female

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* 8. Address

Address

City/Town

State/Province

ZIP/Postal Code

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* 9. Race

White or Caucasian

Black or African American

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Other

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* 10. Ethnicity:

Hispanic or Latino

Non Hispanic or Latino

Prefer not to Answer

Other

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* 11. Have you experienced COVID-19 symptoms?

Yes

If yes, when did your symptoms first start? (MM/DD/YY)

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* 12. Have you been hospitalized for COVID-19?

Yes

If yes, where?

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* 13. Are you a student or staff member for a K-12 school system?

Yes

If yes, where?

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* 14. 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.

I have read the above educational information