Rio Blanco County COVID-19 Self Report Form

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This form is to be used as a tracker for those living in Rio Blanco County to self-report COVID-19 symptoms. Please use this self-screening tool from the CDC for immediate recommendations: https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/index.html

Then visit our website www.rbc.us for specific local recommendations. This tracker will allow us to have a greater understanding of the COVID-19 impact in our community since not everyone will be tested.

Instructions: please complete a form for EACH person in the household who is experiencing symptoms or who has experienced symptoms compatible with COVID-19.

Gender

Male

Other:

Clear selection

Age

0-9 years old

10-19 years old

20-29 years old

30-39 years old

40-49 years old

50-59 years old

60-69 years old

70-79 years old

80 + years old

Clear selection

Is your immune system impacted by another pre-existing health condition?

Yes

Unsure

Clear selection

Do your symptoms include? (Please check ALL that apply)

Fever

Cough

Shortness of breath

Are you also experiencing any of the following symptoms? Please check ALL that apply.

Headache

Chills

Muscle aches

Sore throat

Fatigue

Congestion

Weakness

Loss of taste

Loss of smell

Runny nose

Nausea

Vomiting

Diarrhea

Abdominal pain

None of the above

When did your symptoms first start?

YYYY

What is your zip code?

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