Contact Tracing Survey for Positive COVID-19 Individual

Contact Tracing Survey for Positive COVID-19 Individual

Thank you for choosing to complete our survey! Given the demand on public health resources, Flathead City-County Health Department is requesting your assistance in collecting the following information, which will help us in our response to COVID-19.

Form entries are encrypted, and your information will only be shared when it is necessary to protect the health of the public. Please submit one form for every positive test within your family.

Please complete this form within 24 hours of receiving the link, or someone from Flathead City-County Health Department will be reaching out to you by phone.

If you have questions and/or would rather complete your contact tracing interview by phone, please call us at (406) 751-8250.

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)

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County of Residence*

FlatheadLakeLincolnGlacierSandersOther
Do you live in Montana?

YesNo
Which County Do you Live In?*
Where do you live?
City
State
State

Date of Birth*

MonthDayYear
Country of Birth
Sex at Birth*
Marital Status

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

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.

Have you ever been Hospitalized for COVID-19?*

YesNo
Please select where you were hospitalized
If "other," please type the name of the hospital:
What date were you admitted?

MonthDayYear
Were you admitted to the ICU?

YesNo
Admission Date

MonthDayYear

Where did you get tested?*
What day did you get tested?*

MonthDayYear

Are you employed and/or a student?*

EmployedStudentNeither

Do you work at a school?

YesNo
What school do you work at?
Have you notified your employer that you have tested positive?

YesNo
What was the last day you went to work?

MonthDayYear
Do you wear a mask at work?

YesNo

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)751-8110 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 from isolation:
- If you had no symptoms:
  - You may end isolation after day 5
- If you had symptoms and your symptoms are improving, you may end isolation after day 5 if:
  - you are fever-free for 24 hours (without the use of fever-reducing medication).
- If your symptoms are not improving, continue to isolate until:
  - You are fever-free for 24 hours (without the use of fever-reducing medication).
  - Your symptoms are improving
- If you had symptoms and had:
  - Moderate illness (you experienced shortness of breath or had difficulty breathing).
    
    You need to isolate through day 10.
  - Severe illness (you were hospitalized) or have a weakened immune system
    
    You need to isolate through day 10.
    
    Consult your doctor before ending isolation.
    
    Ending isolation without a viral test may not be an option for you.
  - *If you are unsure if your symptoms are moderate or severe or if you have a weakened immune system, talk to a healthcare provider for further guidance.*
Regardless of when you end isolation:
- Avoid being around people who are more likely to get very sick from COVID-19.
- Remember to wear a high-quality mask when indoors around others at home and in public.
- Do not go places where you are unable to wear a mask until you are able to discontinue masking (see below).
- For travel guidance, see CDC’s Travel webpage.
Removing Your Mask
- After you have ended isolation, when you are feeling better (no fever without the use of fever-reducing medications and symptoms improving) wear your mask through day 10
OR
- If you have access to antigen tests, you should consider using them. With two sequential negative tests 48 hours apart, you may remove your mask sooner than day 10
For any further information on isolation guidelines please visit https://www.cdc.gov/coronavirus/2019-ncov/your-health/isolation.html.
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