CSKT Tribal Health
Positive COVID-19 test self-report form - please fill this form out completely to report a positive COVID-19 test. Each positive individual in the household needs to have a form completed. If requested, you will receive a phone call from a Tribal Health nurse or other appropriate staff.
Name of positive individual
If reporting for a minor, please tell us your name
Birth Date of positive individual
Prefer not to respond
Street Address Line 2
State / Province
Postal / Zip Code
Please enter a valid phone number.
Date tested positive for COVID-19
Where were you tested?
If you were tested at a hospital/clinic/pharmacy/etc, do you know what kind of test result you received?
I don't know
I did a home test
What is your race?
American Indian / Alaska Native
Native Hawaiian / Other Pacific Islander
What is your ethnicity?
Have you been hospitalized for COVID since testing positive?
Have you seen a doctor since testing positive for COVID?
Do/did you have symptoms? (symptoms may include cough, sore throat, congestion, fever, chills, fatigue, headache, loss of taste/smell, body aches, nausea, vomiting, diarrhea)
If you have/had symptoms, what date did they start?
If you had symptoms, what date did they resolve?
Were you a close contact to someone that was diagnosed or tested positive for COVID-19?
Check the symptoms that you had/have during the course of your illness.
Subjective fever (felt feverish)
Cough (new onset or worsening if you have a chronic cough)
Shortness of breath
Nausea or vomiting
Diarrhea (more than 3 loose/looser than normal stools in 24 hours)
Do you have any of these pre-existing medical conditions or risk behaviors?
Severe obesity (BMI greater than 40)
Chronic renal disease
Chronic liver disease
Chronic lung disease
Other chronic diseases
Disability (neurologic, neurodevelopmental, intellectual, physical, vision or hearing impariment)
Do you attend school or work at a school or university? If so, which school?
Are you a healthcare worker? If so, where do you work?
Do you need a letter for work/school?
Would you like a nurse to contact you?
If you had a home test:
Write this link down: hometest.mt.gov --- After hitting submit, visit this website to report your home test to the Montana DPHHS.
What do I do now?
Please note, if you asked for a letter, it will be mailed to the home address you provided. You can expect your letter in 2-4 days following submission of this form. Isolate yourself from all people for a minimum of 5 days from symptom onset OR date of test (if asymptomatic). On day 6, as long as your symptoms are improving AND you are fever free, you may resume normal activities. You MUST wear a mask when around others for another 5 days, even in your own home. Notify all of your close contacts of the need to quarantine. If vaccinated with either primary series or booster in last 6 months, close contacts DO NOT need to quarantine. Call the COVID call line at 406-849-5798 with questions or concerns. Thank you.
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