COVID-19 Initial Notification

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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.

1. What is your first and last name? *This question is required.

2. What is your address (street, P.O. Box, city, state, zip)? Use your local address if you are a student. *This question is required.

3. What county do you live in? *This question is required.

4. What is your preferred phone number? *This question is required.

5. What is an alternate phone number?

6. What is your email address? This question requires a valid email address.

7. What is your date of birth? *This question is required. This question requires a valid date format of MM/DD/YYYY.

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8. If you are under 18, please enter the name of your parent/guardian:

11. Name of your workplace and/or school (if you are a student):

12. What is your job and/or what is your grade in school (if you are a student):

13. Date you last went to work or school This question requires a valid date format of MM/DD/YYYY.

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16. When did your symptoms start? This question requires a valid date format of MM/DD/YYYY.

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16. Date you were tested for COVID This question requires a valid date format of MM/DD/YYYY.

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17. Where did you get tested for COVID? Please be specific with name and location:

22. Name of hospital:

22. City where hospitalized:

22. Date you were admitted to the hospital: This question requires a valid date format of MM/DD/YYYY.

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