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COVID-19 Initial Notification

Please use this secure form to report information about your positive COVID-19 results to District Health Department #10. This will take about 12 minutes to complete. You do not have to answer every question but please be as complete as possible to help us better care for your community. Your work will not save if you close the survey before it is finished. After submitting this survey, we will only contact you if we need more information. If you have any questions you can call us at 231-305-8675  or email info@dhd10.org . If you have any emergency symptoms, like trouble breathing, chest pain, or severe weakness, seek emergency medical care immediately. Follow up with your health care provider as needed. See https://www.dhd10.org/covid-19-now-what/ for more resources.
 
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8. What is your sex at birth?
9. Which of the following best describes you? (Check all that apply) 
10. Which of the following best describes you? (Check all that apply)
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14. Does your workplace or school know you have COVID?
15. Have you had any symptoms during your illness?
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16. Please check all symptoms you have had during this COVID illness: 
16. Are your symptoms all better?
This question requires a valid date format of MM/DD/YYYY.
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18. If your test was done at home, did you notify your primary care provider of the results?
19. Were you pregnant at the time of your COVID illness?
20. Do you live or work at any of the following?
21. Were you hospitalized due to your COVID illness?
This question requires a valid date format of MM/DD/YYYY.
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22. In the two weeks before you started to feel sick (or tested positive if you were never sick) did you visit or attend: