LCHD COVID-19 Screening Form

IF THIS IS A MEDICAL EMERGENCY, PLEASE CALL 911 OR SEEK MEDICAL ATTENTION.

This tool was created for residents of La Crosse County, WI who think they may have had an exposure to COVID-19 or who are having symptoms and have not been able to get tested. In this tool, we define exposures as being within 6 feet for 15 minutes or more OR having contact with bodily secretions (coughs, sneezes, saliva, blood, etc.). There are two ways to be exposed:
1. Directly exposed to a known lab-confirmed case the patient can identify by name, or
2. When an individual was in a location identified by the health department as an outbreak or investigation within the specified dates and times.
If you or an individual for whom you are the legal guardian meets this criteria, please report to us through this form.

I am worried that I was exposed. Will I get COVID-19? COVID-19 spreads easily between people, but not everyone who comes in contact with a positive case will develop COVID-19. Each person's level of risk depends on the nature of their contact as well as other factors like pre-existing health status. Regardless, DO NOT PANIC. Our recommendations are intended to be cautious in order to protect you, your family and our community.

I have symptoms. What do I do? If you have any symptoms of COVID-19, you should stay home. You should not leave your house except to seek medical care (if you do, call before you go). See information about testing referrals below.

Can you refer me for testing? As part of this form, we will screen you to identify if you meet testing criteria; if you do and want to be tested, we will refer you for testing.

What if I don't meet testing criteria? If you do not meet testing criteria, this tool will provide instructions about what to do.

**PLEASE, ONLY COMPLETE THIS FORM FOR YOURSELF OR SOMEONE FOR WHOM YOU ARE THE LEGAL GUARDIAN.**

IMPORTANT INSTRUCTIONS: Complete one form per person.
Are you completing this form for yourself or someone for whom you are the legal guardian? *

Myself My child My parent for whom I am legal guardian Another individual for whom I am legal guardian Someone else for whom I am NOT a guardian

The patient is eligible for testing.
The answers you have provided for this patient indicate that they are eligible for testing.
Does the patient want to be referred by the La Crosse County Health Department for testing? *

Yes, the patient or his/her legal guardian consents to be referred for testing No, the patient does NOT want to be referred

Testing Information
Patient's Date of Birth *

Month Day Year
Date
What type of insurance does the patient have? SELECT ALL THAT APPLY. *

Patient does not have insurance Quartz (can only go to Gundersen if insurance is utilized) Medicare A/B WI Medicaid
Where does the patient prefer to be tested? *

Mayo Clinic (after completing this form, you MUST call Mayo's triage line to be scheduled: 507-293-9525) Gundersen (after completing this form, you MUST call Gundersen's COVID line to be scheduled: 608-775-5412)
With my signature, I consent for this information to be shared with healthcare partners to facilitate COVID-19 testing. I certify that I am authorized to make this consent on behalf of the individual named above as the patient.

Clear
NOTE: Testing referrals may take 24 - 48 hours due to high case volume. Please be patient and await communication via email from the health department or from the testing agency.

Quarantine Instructions
WE ARE NOT ABLE TO CALL PEOPLE BACK, so please read the entirety of these instructions.

If you are an employee of Gundersen or Mayo, contact employee health to discuss your situation.

The patient is not eligible for testing at this time: Currently, we are not able to refer people for testing who do not have symptoms of COVID-19.

If exposed, the patient should be in quarantine: If the patient may have been exposed - defined as being in contact with bodily secretions (including coughs and sneezes) of a lab-confirmed case OR within 6' of a lab-confirmed case for 15 minutes or more - we would recommend that the patient quarantine for 14 days following their last exposure. If they were NOT in close contact as defined above, quarantine may not be required.

If the patient has no symptoms and their employer is requiring testing: Testing capacity does not allow our healthcare partners to test people without symptoms who have a non-specific exposure. You are welcome to show this instruction page to your employer. The best way for employers to prevent the spread of COVID-19 is to ensure thorough cleaning of all high-touch surfaces repeatedly throughout the day, encourage staff to work remotely when possible, actively monitor staff for exposure and signs of illness, require ill staff members with even mild illness to stay home, and follow all guidelines contained in the Coulee COVID-19 Compass.

What to do if things change: During those 14 days, if the patient develops symptoms, they should call their healthcare provider to get tested.

When to contact the health department: If for any reason the patient has symptoms and is NOT able to get tested after contacting healthcare, please submit this form again or call the health department.

NOTE: Due to a high call volume, you may experience a significant delay in receiving a return phone call. Filling out the form will facilitate a faster response.

Isolation Instructions
The patient should be in isolation: You have indicated that the patient (you or someone for whom you are a legal guardian) has symptoms that could be caused by COVID-19. The patient should be in isolation. This means that the patient should stay home, not go anywhere except to seek medical care, and stay away from other household members. The patient should stay in isolation until the following conditions are met: it has been 10 days since symptoms started AND it has been 72 hours with no fever and improvement in other symptoms WITHOUT the use of medication.

If the patient tests negative: If the patient gets tested and tests negative, the patient must still stay in isolation until it has been 24 hours with no fever and an improvement in other symptoms WITHOUT the use of medication. It is possible to test negative, but test positive a few days later.

Household members: Members of the patient's household should be in quarantine - staying at home but away from the ill person, not leaving the home - until 14 days after the patient is well. The only way this recommendation changes is if the patient gets tested and tests negative. If the patient tests negative, household members can be released from quarantine (so long as they have not developed symptoms themselves.

If symptoms worsen: If the patient's symptoms worsen, even if they have tested negative, contact the patient's provider to ask about being retested. If the patient is declined from testing, please resubmit this form or contact the health department.

We are not able to accept submissions for individuals that are not reporting for themselves or someone for whom they are the legal guardian. Please send this link to anyone you know who may want it.

Notes
Please share any information you would like to share here. Note that due to high communication volume, we regret that we will not be able to respond to individual requests.

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Screening

The patient is eligible for testing.

Testing Information

Quarantine Instructions

Isolation Instructions

Notes

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