Case Intake Form

Case Intake Form

This intake form should only be completed by residents of Buffalo County who have tested positive for COVID-19. We try to reach all cases by phone, but due to high case volume, may not be able to reach you as quickly as we would like. We are asking ALL recent cases to complete this form in order to help us speed up our collection of information and sharing important guidance. Sharing this information will help us to ensure quick protection of you, your family, friends, and our community. Your information will be kept confidential and nobody but the health department will have access to your responses. Thank you for your help.
Legal Name *

First Name Last Name
Have you had a laboratory test that confirmed you had COVID-19? *

Yes, I have been diagnosed with COVID-19 with a laboratory test (nasal, throat, or sputum swab, NOT antibody test) No, I have not yet been diagnosed with COVID-19 by a laboratory test
Are you currently living in Buffalo County? *

Yes No

Public Outings
Beginning from 2 days before your symptoms started (or when you were tested) through today, did you go in-person to any public locations such as a store, bar, restaurant, concert, conference, etc.? Do NOT include work, school or other outings already discussed. *

Yes, I went to another public location that I haven't yet talked about No, I have not been to a public location that I haven't yet talked about
Please list any locations you went to starting 2 days before your symptoms started (or when you tested) through today, including the dates and times you went to each establishment. Please be specific. If you aren't sure about a detail, provide as much information as you do remember. Some details are better than no details *

Close Contacts
Beginning from 48 hours before symptoms started (or if you have never had symptoms, 48 hours before your test was conducted) through today's date, what people were you in close contact with? Close contact could be someone who: (1) you were within 6' of for at least 15 minutes or more, (2) was next to you when you were coughing, sneezing, spitting or singing for any length of time, OR (3) you had direct physical contact with. Select all that apply *

Close contact with coworkers Close contact with friends/acquaintances who don't live in my household Close contact with family who don't live in my household Close contact with others not included above No close contacts with anyone outside of household
Please enter the name, relationship and phone number for anyone you have not already listed with whom you had close contact (within 6 feet for more than 15 minutes throughout the day or direct physical contact). You may have to scroll over to access all of the fields. *
The Buffalo County Health Department tries to reach all high-risk close contacts. "High risk" includes household members, significant others, and individuals with prolonged exposures who are at high risk of severe disease. We are not able to call all close contacts during times with high case numbers. For this reason, please notify your own close contacts. Information about how to do so - including a resource that will allow you to notify them anonymously - can be found here:

Next Steps: I tested positive for COVID-19. What can I do to help notify my close contacts of their exposure?

Next Steps: Close Contacts of Someone with COVID-19

Isolation Reminder
Isolation Guidance for You (The Case)

How Does COVID-19 Spread: 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.

This is why you must stay in isolation. Isolation means that you do not leave you house, unless you need medical care. If you live with other people, you should stay away from them as much as possible. Have food dropped of at your door if possible. If you need to go into parts of your home that are shared spaces, wear a mask at all times. If you use a common space such as a bathroom or kitchen, you should wipe down all surfaces with a cleaning product after you use it. You must stay in isolation even if you feel better.

Do not end your isolation until you are told it is safe to do so.

It will be safe for you to end isolation when:
- It has been at least 10 days since your symptoms began (or your test was conducted if you have not had symptoms), AND
- You have had no fever for 24 hours without using medication that would reduce the fever, such as tylenol or advil, AND
- Any other symptoms have been improved for 24 hours without using medication that would improve them.
When to Get Medical Help: If you experience a worsening of symptoms and/or find it difficult to breathe, you should seek medical care. It is important that you call ahead to indicate that you are positive for COVID-19; they will have you go to a special entrance. If you need to call 911, be sure to indicate that you need medical care but that you are positive for COVID-19 and are in isolation at your home. They will send a special ambulance that will safely transport you to the hospital.

The Buffalo County Health Department wishes you a speedy recovery. Thank you for doing your part to keep our community safe.

Quarantine Guidance for Close Contacts & Household Members

What Your Household Members/Close Contacts Should Do: Someone is considered "contagious" starting 2 days before their symptoms started or 2 days before their test was done if they hadn't yet developed symptoms. Anyone who has had direct contact with you for any length of time (a hug, kiss, high five, etc.), or who was within 6 feet of you for 15 minutes or more, while you were contagious is considered "exposed."

Anyone exposed who is not vaccinated and has not been diagnosed with COVID-19 in the past 90 days should quarantine. This means they stay at home and away from others so that if they are developing illness, they do not expose others. It is best to quarantine for 14 days after the most recent exposure.

Anyone exposed who is vaccinated or who has had been diagnosed with COVID-19 in the past 90 days does NOT have to quarantine. Vaccinated individuals who are exposed should wear a mask in public and when around other people, and should be tested 3 - 5 days after exposure. If symptoms develop or worsen for the individual in quarantine, they should isolate away from others and get tested immediately.

The Buffalo County Health Department wishes you a speedy recovery. Thank you for doing your part to keep our community safe.
Are you submitting this form for yourself, someone in your household, or a patient? *

Self Someone else in my household I work for a healthcare institution and am completing this form with the patient or their legal guardian Other
Abiding by these instructions will help to keep you, your family and our community safe. By checking this box, you agree that you have read these instructions or had them explained to you. *

Yes, I have read these instructions or had them explained to me.
If you have any further information you would like to share about where you think you came into contact with the virus or anything else about your situation you would like us to know, please add it here. Please note that we will not respond to questions through this form. If you have questions that require a response, please contact your provider or call/email the health department.

This form is only for laboratory-confirmed positive cases of COVID-19 living in Buffalo County. If you have questions about an exposure, being tested, have a question about something else, please call the health department's main line at (608) 685-4412.

You have reached the end of the form. Thank you for taking the time to complete it. Please select "submit".

If you have any questions or concerns, please call the health department's main line at (608) 685-4412.
Should be Empty:

Case Intake Form

Symptom Onset/Preexisting Conditions

Source of Infection

Occupation and School

Public Outings

Close Contacts

Isolation Reminder

You have reached the end of the form. Thank you for taking the time to complete it. Please select "submit".