COVID-19 Case Investigation Form

COVID-19 Case Investigation Form

Lake County Public Health
Thank you for choosing to complete our COVID case survey. Lake County Public Health Department 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 case interview by phone, please call us at 406-883-7288.
Reporting for myselfReporting for someone else
Name of Patient*

First NameLast Name
Name of Person Filling Out Form *

First NameLast Name
Relationship to Patient*

Name

First NameLast Name
Date of Birth

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

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 have questions, please contact us at 883-7288.
High Risk Close Contacts
Should be Empty: