PLEASE ONLY FILL OUT THIS FORM IF YOU HAVE BEEN CONFIRMED POSITIVE FOR COVID -19 AND ARE A KNOX COUNTY RESIDENT. This information is used to get a better understanding of who this disease is affecting and prevent further spread. Your information is confidential.  

If you have any questions, or would like to discuss this matter further, please call 740-399-8003. For more information on COVID-19, please visit www.knoxhealth.com

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* 1. First Name (of positive person)

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* 2. Last Name (of positive person)

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* 3. Date of Birth

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* 4. If case is a minor, Parent or Guardian Name. If not a minor please write NA.

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* 5. Address (including City, State, Zip)

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* 6. Phone Number

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* 7. Email

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* 8. Sex

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* 9. Race

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* 10. Ethnicity

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* 11.
Symptoms & Test Date

Date
Date

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* 12. Testing information

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* 13. Did your home test include a video visit/telemedicine component? (If you are using an at-home COVID-19 test kit, you MUST have the test proctored (supervised by a health professional) by the manufacturer's testing service. Knox Public Health will not provide isolation letters if we do not have the proper documentation)

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* 14. Vaccine Information

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* 15. Are you still symptomatic?

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* 16. Were you ever hospitalized for your COVID-19 symptoms?

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* 17. Occupation (Check all that apply)

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* 18. Workplace/School Information

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* 19. You can be contagious 2 days prior to your symptoms starting (If asymptomatic, 2 days prior to the day you were tested). If you work/attend school outside of the home, were you at work/school during your contagious period?

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* 20. Do you smoke?

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* 21. Did you test positive for any other respiratory conditions?

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* 22. Exposure Information

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* 23. Have you been in contact with someone who was ill within the last two weeks?

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* 24. If yes, please indicate where the contact occurred 

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* 25. Have you attended any events  or public gathering in the last two weeks (weddings, funerals, family gatherings, etc)?

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* 26. Please list any HOUSEHOLD (individuals who live in your home) contacts and you MUST include the following: Name and Cell Phone Number. Please inform your household contacts of their quarantine status.

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* 27. Please list any NON household (individual whom you have interacted with more than 15 minutes, without a mask, closer than 6ft apart, within 48 hours of your symptoms onset or positive test date if not symptomatic) contacts and include the following: you MUST include the following: Name, Cell Phone Number, and your last date of contact with the individual. Please inform your close contacts of your positive status and their quarantine requirements.

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* 28. Please indicate if you prefer to share your positive status with your close contacts or if you prefer to remain anonymous. If you prefer to remain anonymous the health department will reach out to your close contacts to inform them of their quarantine status. Your name will not be shared. 

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* 29. Are there any questions you need answered or anything else you would like to ask us about your illness?

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* 30. What is your preferred method of contact?

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* 31. Does your Employer/School require a letter to return after isolation?

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