MCHD Case Intake Form

This intake form is for positive cases of COVID-19 living in Manitowoc County. If you have questions about an exposure or being tested, please visit our website and/or contact the Health Department. 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.

https://manitowoccountywi.gov/departments/health-department/covid-19-information/
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
Legal Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Phone Number

Area Code Phone Number
Email Address:
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Are you currently living in Manitowoc County? *

Yes No

What county do you live in?
If you live outside of Manitowoc County, The Manitowoc County Health Department will notify the county in which you reside.
Isolation Information

Isolation means: You have tested positive for COVID-19 and 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. 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 remain in isolation for at least 5 days from your positive test date. The test date would be considered day zero. For example, if you got tested on 12/1/2021 you should be on isolation through 12/06/2021 and able to resume usual activities on 12/07/2021.You may only exit isolation when you meet the following criteria:
- You have not had a fever for at least 24 hours (without fever- reducing medication)
- Your symptoms are resolving
- It has been at least 5 days since you had your first symptoms or a positive test.
You MUST continue to wear a mask around others for 5 additional days

If you have a fever, continue to stay home until your fever resolves.

When to Get Medical Help: If you experience a worsening of symptoms and/or find it difficult to breathe, you should seek medical care.
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. *

Yes, I have read these instructions or had them explained to me.
Would you like a letter with your isolation and/or close contact's quarantine dates. (This information will be sent to you in the mail) *

Yes No

By submitting this form, you are helping to control the spread of COVID-19.
Should be Empty:

Isolation Information