COVID-19 Case Investigation Form

COVID-19 Case Investigation Form

Ravalli County Public Health
Thank you for choosing to complete our contact tracing survey. Due to the high volume of COVID-19 cases, Ravalli County Public Health is requesting your assistance in collecting the following information to assist us in our COVID-19 response efforts. This survey is only for individuals who have tested positive for COVID-19. Please do NOT complete it unless you have had a positive test. All 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. This survey is intended for individuals 18 years of age or older. If you are under 18 please have your parent/guardian complete the survey for you. If you have questions and/or would rather complete your contact tracing interview by phone, please call Public Health at 406-375-6672.
Are you reporting for yourself or someone else?*

Reporting for myselfReporting for someone else
Name of Patient*

First NameLast Name
Name of Person Filling Out Form *

First NameLast Name
Relationship to Patient*

Date of Birth*

MonthDayYear
(MM-DD-YYYY)
Sex at birth*

MaleFemalePrefer not to say
Address (if multiple, please use the address you live at majority of the year)*

Address Line 1

Address Line 2

Address CityAddress State

Address Zip
Primary Phone Number*
Please enter a valid phone number.

Close contacts

A close contact is anyone you were within 6 feet of for 15 minutes or more during your infectious period, regardless of whether you or they were masked. You are able to infect others starting two days prior to your first symptom and for 5-10 additional days starting the day of your symptoms. Please share the information below with anyone that meets the above criteria.
Isolation instructions (if you tested positive for COVID-19) After you test positive for COVID-19 you must remain isolated until you meet the criteria from the Centers for Disease Control and Prevention (CDC) to be released from isolation. Please stay home and isolate yourself from others to prevent the spread of COVID-19. Isolation means staying home for at least 5 days since your symptoms began, or day of your positive test if you are asymptomatic (never develop any symptoms). In order to be released after day 5 of isolation, it is strongly recommended that you continue to wear a mask around others for 5 additional days and the following criteria must be met: You have not had a fever in the last 24 hours (without the use of fever reducing medication); and You do not have a cough, sneezing or other respiratory-like symptoms and other symptoms are resolving. If you have access to an at-home test kit, we would encourage you to test at day 5 prior to releasing yourself from isolation. If you continue to have respiratory symptoms, you must remain in isolation for the full 10 days from symptom onset and can be released after 10 full days if: You have had some improvement in symptoms; and You have not had a fever in the last 24 hours (without the use of fever reducing medication). Quarantine instructions (if you are a close contact to a positive COVID-19 case) can be found at https://ravalli.us/207/Public-Health Vaccine Status Quarantine Recommendation If you: • Have received a booster shot; OR • Completed the primary series of Pfizer or Moderna within the last 5 months; OR • Completed the primary series of J&J within the last 2 months. • Wear a mask around others for 10 days. • Test on day 5, if possible. • If you develop symptoms, get tested and stay home. • Completed the primary series of Pfizer or Moderna over 5 months ago and are not boosted; OR • Completed the primary series of J&J over 2 months ago and are not boosted; OR • Are unvaccinated. • Quarantine at home for 5 days. After that continue to wear a mask around others for 5 additional days. • If you are unable to quarantine, wear a mask around others for 10 days. • If you develop symptoms, get tested and stay home. Source: https://www.cdc.gov/coronavirus/2019-ncov/your-health/quarantine-isolation.html
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Enter the day of symptom onset (or test date if asymptomatic)*

MonthDayYear
Date
Last date of isolation if fully asymptomatic or if mildly symptomatic with some improvement and you have NOT had a fever in the past 24 hours:

MonthDayYear
Date
Last date of isolation if symptoms are severe and/or not improving:

MonthDayYear
Date
Thank you for completing our case investigation survey. Please print this page for your own records or to provide documentation to your employer or school. If you require assistance from case management services in order to safely isolate, please contact Public Health 406-375-6672 or email us at rcpublichealth@rc.mt.gov.
High Risk Close Contacts
Should be Empty:

COVID-19 Case Investigation Form

Close contacts