Contact Tracing Survey for Positive COVID-19 Individual

Are you filling this out for yourself or someone else? Please submit one form for every positive test within your family.*

MyselfSomeone else
Name of Patient*

First NameMiddle NameLast Name
Name of Patient*

First NameMiddle NameLast Name
Name of Person Filling Out Form*

First NameLast Name
Relationship to Case*
Contact Number (If different than case)

Cell Phone*
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Email
We collect this information in case we need to confirm quarantine/isolation dates for yourself, your family, or other close contacts.

We strongly encourage you to contact your school and notify them of your illness and the need to isolate.
Where do you go to school?*
What was the last day you went to school?

MonthDayYear
Do you wear a mask at school?

YesNo
Do you participate in any school related sports or extracurricular activities?

Yes, more than oneYesNo
What is the activity?
Please list the activities
What is the last date you participated in the activity?

MonthDayYear
Date
What is the last date you participated in your first activity?

MonthDayYear
Date
What is the last date you participated in your second activity?

MonthDayYear
Date
What is the last date you participated in your third activity?

MonthDayYear
Date

Have you been around anyone you've known to be positive for COVID-19?

YesNo
Are there any individuals that you have been within 6ft of for 15 minutes or more during your infectious period (close contact)?

YesNo
Please notify your close contacts about their possible exposure. Close contacts who have questions may call the COVID-19 Information Line at (406)751-8250 or visit our website at flatheadhealth.org for more information about COVID-19 quaratine recommendations.

Have you ever received a COVID-19 vaccine?

YesNo
How many doses of COVID-19 vaccine did you receive prior to onset of symptoms or, if you didn't have symptoms, your most recent positive test?

One (1)Two (2)Booster
What was the brand of your vaccine?
What was the brand of your booster?
Please either take a photo or submit an image of your vaccination card:
Take Photo

Flathead County has recently adopted new guidance regarding COVID-19 isolation and quarantine. The Health Department is no longer recommending quarantine of close contacts. Please refer to the CDC press release for more information.
Enter the day of symptom onset*

MonthDayYear
Your release date will be on if you meet the below criteria
Criteria for release: Feel 50% better from your worst day, and 24 hours fever free without fever reducing medications. It is current CDC recommendation to get tested on day 5 of isolation. If you test positive, remain in isolation for an additional 5 days. If you test negative and meet the other criteria, you may release from isolation but continue to wear a well-fitted mask through day 10.
Should be Empty:

Screening Tool