Covid-19 Case Details

Covid-19 Case Details
IMPORTANT: Please complete this form if you have tested positive for COVID19. If you have tested negative and/or have had no symptoms DO NOT complete this form.
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Gender (Given at birth)
Ethnicity (Check all that apply) *

Hispanic/Latino Non-Hispanic/Latino Arab Non-Arab Unknown
Race (Check all that apply) *

Caucasian Black/African American American Indian/Alaska Native Hawaiian/Pacific Islander Asian Unknown Other
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
What County do you live in? *
Preferred Phone Number *
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Email
example@example.com
Check yes if you'd like us to email you resources regarding self isolation or quarantine for your close contacts.

Yes, please email me resources
Parent/Guardian (required if under 18)

First Name Last Name
Did the person attend a community event of mass gathering? (e.g. concert, rally, parade, wedding, etc.) *

Yes No
If yes, what type or name of the event?
Has the patient traveled to a non-U.S. country? *

Yes No
If yes, where?
Has the patient traveled in the U.S. outside of their home state? *

Yes No
If yes, where?
Has the patient traveled within Michigan? *

Yes No
If yes, where?
Has the patient traveled on a cruise ship? *

Yes No
If yes, where?
Symptomatic? *

Yes No
If symptomatic, when did symptoms start?

Month Day Year
Date
If yes, what are your symptoms?

Fever Rigors Cough Headaches Fatigue/Lethargy/Weakness Difficulty Breathing Evidence of Pneumonia Multi-Organ Dysfunction Syndrome (MODS) Muscle aches Shortness of breath Abdominal pain Congestion Chest pain Confirmatory chest x-ray or CAT scan for Pneumonia Acute Respiratory Distress Syndrome (ARDS) Runny nose Nausea Diarrhea (>3 loose/looser than normal stools/24 hour period) Encephalopathy/Encephalitis Loss of taste Toxic state (sepsis) Chills Sore Throat Vomiting Wheezing Loss of smell Seizure Stroke/Venus Thromboembolism (VTE)
Please check yes if any of the following apply: *

Were you hospitalized? Have your symptoms resolved? Were you pregnant at the time of illness? Do you smoke? Do you vape? Use/misuse substances None of the above
Do you take any of the following medications? *

Aspirin or aspirin containing products Chemotherapy Radiation therapy Oral steroids Other immunosuppressive medications None of the above
Date of test *

Month Day Year
Date
Date isolation was started *

Month Day Year
Date
Were you in quarantine when symptoms started? *

Yes No
Has workplace been notified *

Yes No Not Applicable
If patient is a student, has school been notified *

Yes No Not Applicable
Date last worked/attended school

Month Day Year
Date
Where was the patient staying at the time of illness onset (Or at the time of positive for asymptomatic individuals)? *
Does the patient live or work in one of the following? *
If you're a healthcare worker, what is your occupation? *
If you're a healthcare worker, what is your job setting? *
Name of school patient attends, if applicable.
Name of workplace of patient, if applicable.
Do you know where you were exposed? *

Yes No
How (or by whom) were you exposed *
How (or by whom) were you exposed *
Address of school or workplace (If applicable)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Address of school or workplace

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Do you have any pre-existing conditions? *

Yes No Unknown
Please check all that apply. *

No pre-existing or chronic conditions Asthma/Reactive Airway Disease Chronic Liver Disease Hypertension Autoimmune condition Chronic Lung disease/COPD/Emphysema Neurologic Disease Other Immunosuppressive Condition Cancer Chronic Renal Disease Severe Obesity (BMI >40) Psychological/psychiatric condition Cardiovascular Disease Diabetes Mellitus Other Chronic Disease
Please specify "other" condition.
List Close Contacts Here

A close contact is someone who was closer than 6 feet, for 15 minutes or more -this is cumulative time throughout the day- with or without masks to the COVID -19 positive person during their contagious period.

The contagious period begins 2 days before symptoms start, (or 2 days before testing if no symptoms) and goes until the positive person was isolated from others.

IMPORTANT: These individuals must quarantine for 14 days starting the day they were last in contact with the positive case. If close contact tests negative, they must complete the full 14 days of quarantine since symptoms may appear 2 to 14 days after exposure to the virus.
- Any time a new household member gets sick with COVID-19 and you had close contact, you will need to restart your quarantine.
- If you cannot avoid close contact with the person who has COVID-19, avoid contact with others outside the home while the person is sick, and quarantine for 14 days after the person who has COVID-19 meets the criteria to end home isolation.
Contacts of a contact do not need to quarantine but should monitor themselves for symptoms.

It is recommended for close contacts of a positive case to wait 5-7 days after exposure to obtain testing if asymptomatic.
1. Contact Name

First Name Last Name
Relationship to contact
Minor?

Yes No
Please indicate what school the child attends & if he/she is virtual or in person learning
Parent/Guardian (required if under 18)

First Name Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
(If known) county of residence
Date of Last contact

Month Day Year
Date
2. Contact Name

First Name Last Name
Relationship to contact:
Minor?

Yes No
Please indicate what school the child attends & if he/she is virtual or in person learning
Parent/Guardian (required if under 18)

First Name Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
(If known) county of residence
Date of last contact

Month Day Year
Date
3. Contact Name

First Name Last Name
Relationship to contact:
Minor?

Yes No
Please indicate what school the child attends & if he/she is virtual or in person learning
Phone Number
Please enter a valid phone number.
Email
example@example.com
(If known) county of residence
Date of last contact

Month Day Year
Date
4. Contact Name

First Name Last Name
Relationship to contact:
Minor?

Yes No
Please indicate what school the child attends & indicate if he/she is virtual or in person learning
Parent/Guardian (required if under 18)

First Name Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
(If known) county of residence
Date of last contact

Month Day Year
Date
5. Contact Name

First Name Last Name
Relationship to contact:
Minor?

Yes No
Please indicate what school the child attends & if he/she is virtual or in person learning
Parent/Guardian (required if under 18)

First Name Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
(If known) county of residence
Date of last contact

Month Day Year
Date
Please add additional close contacts or any other information you think we need to know.
IMPORTANT:

A person with a positive COVID-19 test must isolate for 10 days past symptom onset or test collection date.

I tested positive for COVID-19 but had no symptoms

If you continue to have no symptoms, you can be with others after 10 days have passed since the date of test collection.

If you develop symptoms after testing positive, follow the guidance (I tested positive for COVID-19 but had symptoms) below:

I tested positive for COVID-19 and had symptoms

You can be with others after:
- At least 10 days since symptoms first appeared and
- At least 24 hours with no fever without fever-reducing medication and
- Other symptoms of COVID-19 are improving*
  *Loss of taste and smell may persist for weeks or months after recovery and need not delay the end of isolation
IMPORTANT: People who have tested positive for COVID-19 do not need to quarantine or get tested again for up to 90 days as long as they do not develop symptoms again.

If you have recovered from your symptoms after testing positive for COVID-19, you may continue to test positive for three months or more without being contagious to others. For this reason, you should be tested only if you develop new symptoms of possible COVID-19.
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