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CMDHD Individual self-reporting tool (COVID-19)

Please use this secure form to report your own positive COVID-19 results to Central Michigan District Health Department. After submitting this survey, we will contact you if we require additional information.
This question requires a valid date format of MM/DD/YYYY.
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This question requires a valid date format of MM/DD/YYYY.
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This question requires a valid date format of MM/DD/YYYY.
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This question requires a valid date format of MM/DD/YYYY.
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10. If you work, please choose what type of business that you work for.
13. Did you let your workplace know that you tested positive for COVID-19?
14. Do you have any school-aged children? *This question is required.
15. Close Contacts: A close contact is someone who was closer than 6 feet for 15 minutes or more (cumulative time throughout the day), to the COVID-19 positive person during their contagious period, either with or without wearing masks. Individuals identified as close contacts must quarantine for 14 days after they were last in contact with the positive person.  Are there any close contacts that you have identified? *This question is required.
16. List any close contacts here.   Think of work, school, family and friends.  These individuals must quarantine for 14 days after they were last in contact with you.  Even if the close contacts test negative, they must complete the full 14 days of quarantine. If you do not know this information yet, please submit the form and we will follow up with you.
Space Cell Name (first and last)Date of last contact with the positive personPhoneEmailCounty of residence (if known)Any other information you would like to share
Close Contact #1
Close Contact #2
Close Contact #3
Close Contact #4
Close Contact #5
Close Contact #6
Close Contact #7
Close Contact #8
Close Contact #9
Close Contact #10