Online COVID-19 Case Self-Reporting Form

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By completing this form, you are reporting to Crawford County Public Health that you or someone in your care has tested positive for COVID-19. Completing this form as thoroughly as possible will help our staff properly capture your disease experience. Thank you for your assistance.

Last Name *

First Name *

Street Address *

City and Zip Code *

Phone Number *

Date of Birth *

YYYY

Gender *

Male

Female

Race

White

Asian

American Indian or Alaskan Native

Black

Hawaiian Native or Pacific Islander

Other

Prefer not to answer

Clear selection

Ethnicity

Hispanic

Non-Hispanic

Prefer not to answer

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Workplace/School

Last Day of Attendance

YYYY

Date of Positive Test

YYYY

Number of household or close contacts

Did you seek medical care (e.g. telemedicine, clinic, urgent care, or emergency room) from 2 days before or 2 weeks after your positive test?

Yes

Clear selection

Were you hospitalized for any reason due to your COVID-19 symptoms?

Yes

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If hospitalized, please list dates

If you are/were ill, what symptoms are/were you experiencing? Please check all that apply. If none, check no symptoms.

NO SYMPTOMS

Fever

Chills

Rigors (Sudden feeling of cold with shivering with a rise in temperature)

Muscle aches (myalgia)

Runny nose (rhinorrhea)

Sore throat

Cough (new onset or worsening of chronic cough)

Wheezing

Shortness of breath (dyspnea)

Chest Pain

Nausea or vomiting

Headache

Tiredness/Fatigue

Abdominal pain

Diarrhea (3 or more looser than normal stools in a 24 hour period)

Loss or change in your sense of taste or smell

Difficulty breathing

Conjunctivitis (eye drainage, watery, pink, irritated)

Confusion or change in mental status

Persistent pain or pressure in the chest

Pale, gray, or blue-colored skin, lips or nail beds

Inability to wake or stay awake

Nasal Congestion

Other

Date symptoms started

YYYY

Are your symptoms resolved?

Yes

Clear selection

Date symptoms resolved

YYYY

Do you have a pre-existing health condition? (including asthma, diabetes, cardiovascular disease, etc)

Yes

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If yes to above question, please list conditions below

Are you a healthcare worker:

Yes

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How would you describe your smoking status?

Current

Former

Never

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Have you received a COVID-19 Vaccine?

Yes

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If yes, Type of Vaccination *

Moderna

Pfizer

Johnson & Johnson

N/A

1st Dose

2nd Dose

3rd Dose

4th Dose

Dates of Vaccinations

If you need further assistance, please call 419-562-5871 and dial extension 1204. Thank you

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