Online COVID-19 Case Reporting Form

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By completing this form, you are reporting to the Union County Health Department that you or someone in your care has tested positive for COVID-19. Please complete the information below as thoroughly as possible. While most locations, no longer require an isolation or quarantine letter, if you need this, please be sure to indicate in the appropriate field below. If this form is completed in its entirety, UCHD staff WILL NOT be calling to follow-up. If you need to calculate your isolation or quarantine timeframe, please visit the CDC website. Thank you for your assistance.

Last Name *

First Name *

Address (Street Address, City, State, Zip Code) *

Telephone Number *

Date of Birth *

YYYY

Sex *

Female

Male

Other:

Race *

White

Asian

Amer. Indian or Alaskan Native

Black

Hawaiian Native or Pacific Islander

Other

Prefer not to answer

Ethnicity *

Hispanic

Non-Hispanic

Prefer not to answer

Employer, School, or Daycare Name and Date of Last Attendance

Date of Positive COVID Test

If you have a positive test result, please email a picture of it to us at covidepi@uchd.net or text a picture to our lead epidemiologist at ‪(937) 210-9538‬ with your name.

YYYY

Where was the test administered? (If you have tested positive through various means, check all that apply.)

At Home

Pharmacy

Testing Site/Center

Urgent Care

Provider's Office/Hospital

No test completed

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

Yes

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

Fever > 100.4F (38C)

Subjective fever (felt feverish)

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 loose/looser than normal stools/24hr period)

Loss or change to 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

No Symptoms

Date Symptoms Began

YYYY

Do You Have a Pre-existing Health Condition? (including asthma, diabetes, cardiovascular disease, etc). *

Yes

Are You a Healthcare Worker?

Yes

Clear selection

Do You Know Where You Were Exposed to COVID-19? Please select exposure setting, if known. *

Household

Community (friends, social circle, visiting family)

School

Workplace

Community Event/Mass Gathering (concert, church, etc.)

Travel

Healthcare Associated

Unknown

Other:

How Would You Describe Your Smoking Status? *

Current

Former

Never

Have You Received a COVID-19 Vaccine? *

Yes- 1 dose

Yes- 2 doses

Yes- 3 or more doses

Do you require a proof of isolation letter? (Please note, most Union County schools need documentation for any days missed.)

Yes

Clear selection

Email Address *

Submit

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