Case Intake Form

De Pere Health Department

COVID-19 Case Intake Form
We ask that ALL recent positive COVID-19 cases who have not already been reached by phone complete this form. Only questions with * are required. Your information will be kept confidential and no one but the health department will have access to your responses. Thank you for your help to keep our community safe and healthy!
Have you had a POSITIVE COVID-19 test in the last 14 days?*

Yes, I have been diagnosed with COVID-19 via a laboratory-processed test (nasal/throat swab or saliva, PCR or antigen)Yes, I have taken a self-administered/read COVID-19 test at home that was positiveNo, I have not had a recent positive COVID-19 test
Are you currently living in the city of De Pere?*

YesNo
If you live outside the city limits of De Pere, please contact the appropriate health department for your jurisdiction: https://www.dhs.wisconsin.gov/lh-depts/counties.htm

If you have questions about an exposure, testing, or something else, you can email us at deperehealth@deperewi.gov or visit: https://www.deperewi.gov/department/index.php?structureid=12

If you received a negative test or a positive antibody test result, no public health follow-up is needed.

If you have symtpoms of COVID-19 but have not been tested, please find a testing site near you: https://www.dhs.wisconsin.gov/covid-19/community-testing.htm
Isolation Reminder

In order to prevent the spread of COVID-19 to others, you should ISOALTE if you have a positive test result or have symptoms of COVID-19.
COVID-19 is spread from one person to another through body fluids like saliva that come out of your mouth and nose when breathing, talking, singing, coughing or sneezing. It is very easy to spread, which makes it very important that you stay away from other people while you get better.

Isolation means that you do not leave your house, unless you need medical care. If you live with other people, you should stay away from them as much as possible.

Everyone who tests positive for COVID-19, regardless of vaccination status, MUST isolate:
- Stay home (isolate) and away from others for 5 days
- If you have no symptoms or your symptoms are resolving after 5 days, you can leave your house
- Continue to wear a mask around others for 5 additional days
- If you have a fever, continue to stay home until your fever resolves
For more information: https://www.dhs.wisconsin.gov/covid-19/diagnosed.htm

For help with isolation dates, use this isolation calculator:

https://doh.sd.gov/covid/calculator/

Contact Information
Legal Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Phone Number*

Area CodePhone Number
Email
example@example.com
Exposure Source
Have you been exposed to someone who is a laboratory confirmed case of COVID-19?

YesNo/Unsure
Details/Name:
In the 14 days prior to developing symptoms (or being tested if you did not have symptoms), did you travel or attend a gathering, such as a get-together with friends, a party, a wedding or a business place where many people were present such as a bar?

YesNo
Details:
Symptom Onset
Do you now have, or have you had, any of the following symptoms in the past 2 weeks?*

Cough (new onset or worse than normal if chronic)Abnormal tirednessFever (100.0 F or higher) or feeling feverishMuscle achesChills or body shakingSore throatStomach upset (diarrhea, nausea, vomiting - new onset or worse than normal if chronic)Feelings of tightness in chestShortness of breath or difficulty breathingCongestion or runny noseHeadacheNew loss of taste or smellNo, I have not had any of these symptoms
What date did your earliest symptoms begin? Choose the earliest date that you felt any symptom, no matter how mild.*

MonthDayYear
Date
Testing
Date Positive Test was COLLECTED*

MonthDayYear
Date
Testing Site/Details:
Household Contacts
People who you live with are most at risk for developing COVID-19, especially if they have not previously had COVID and/or are unvaccinated. To learn more about protecting your family: https://www.dhs.wisconsin.gov/publications/p02800.pdf
How many people live in your household, including yourself? If you live alone, enter "1."
Please provide the following details regarding your household members. To enter additional people, click "Press to add another."
Close Contacts
A close contact is anyone during your infectious period who was within 6 feet of you for a total of 15 minutes or more over a 24-hour period, had direct exposure to your respiratory secretions (coughed or sneezed on, shared a drinking glass, utensils, towels, or other personal items), had direct physical contact with you (hug, kiss, or handshake). They are at risk now for developing COVID-19 also and should QUARANTINE.

Exposure to Someone with COVID-19 (Quarantine)

If your close contact....

Had booster vaccination OR completed the primary series of Pfizer or Moderna vaccine within the last 5 months OR completed the primary series of J&J vaccine within the last 2 months OR are 5-11 years old and completed a primary series of Pfizer more than 2 weeks ago:
- Wear a mask around others for 10 days
- Test on day 5, if possible
- If symptoms develop, get a test and stay home
Completed the primary series of Pfizer or Moderna vaccine over 5 months ago and are not boosted OR completed the primary series of J&J over 2 months ago and are not boosted OR completed any primary series less than 2 weeks ago OR is unvaccinated:
- Stay home for 5 days
- After that continue to wear a mask around others for 5 additional days
- Test on day 5 if possible
- If symptoms develop, get a test and stay home
For more information:

https://www.dhs.wisconsin.gov/covid-19/close-contacts.htm

https://www.dhs.wisconsin.gov/publications/p02598a.pdf

For help with quarantine dates visit: https://doh.sd.gov/covid/calculator/
Beginning 2 days before your symptoms started (or if you have never had symptoms, 2 days before your test was conducted) through today's date, did you have close contact with anyone other than your household members?

YES, I had close contact with others (please list below if able)NO, I have had no close contact with anyone outside of my household
Please enter the name, relationship and phone number for anyone other than members of your household with whom you had close contact.
We are not able to call close contacts during times with high case numbers. For this reason, please notify your own close contacts if possible. Information about how to do so (anonymously if needed) can be found here:

https://www.dhs.wisconsin.gov/publications/p02803.pdf
Other Contacts

There maybe be others that are at risk for COVID-19 who you do not know or have contact information for- please help us identify additional contacts by answering below.
Do you have a job/do you volunteer?

YesNo
In what business(es) or establishment(s) have you worked/volunteered during the past two weeks? If you work in more than one place, please list all that apply.
Are you currently a student or attend daycare?

No, I am not a StudentYes, I am a university/college studentYes, I am a grade school studentYes, I attend daycare
School/Daycare Name & Address
Starting from the two days before symptoms started (or positive test) through today, which dates did you work/volunteer or attend school/daycare?
Have you notified the places listed above about your positive result?

NoYes
Beginning 2 days before symptoms started (or if you have never had symptoms, 2 days before your test was conducted) through today's date, have you been in-person to any other public locations or did you travel?

I have not been to any public location during this time periodI was at a public location in my infectious period- listed belowI traveled during my infectious period- details below
Please list ALL locations you went to during this time period, including the dates and times you went to each establishment. Please be specific. If you aren't sure, provide as much information as you do remember. Some details are better than no details.
Please list as much detail about your travel as possible (dates, flight numbers/seat number, travel companions, hotel info, etc.)
You have reached the end of the form. Thank you for your help. Press "Submit."
Should be Empty:

Isolation Reminder

Contact Information

Exposure Source

Symptom Onset

Testing

Household Contacts

Close Contacts

Other Contacts

You have reached the end of the form. Thank you for your help. Press "Submit."