CMDHD Individual self-reporting tool (COVID-19)

Please use this secure form to report your positive COVID-19 results to Central Michigan District Health Department. After submitting this survey, we will contact you if we require additional information.

1. Today's Date
This question requires a valid date format of MM/DD/YYYY.

calendar

2. What is your first and last name?

(You/your = the person who tested COVID positive. If you are a parent/guardian/spouse filling this out for someone else, there is a place to put your name at the end of the survey) *This question is required.

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

calendar

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

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

6. What is your phone number? *This question is required.

8. Date of COVID-19 test? *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

9. Where were you tested? *This question is required.

If you have symptoms, what day did your symptoms start? This question requires a valid date format of MM/DD/YYYY.

calendar

What is the name of the school, daycare, pre-school, long-term care facility, jail/prison, group home, shelter, or dormitory? *This question is required.

What school/s do your children attend? *This question is required.

What grades? *This question is required.

13. If you are a parent/guardian/spouse filling this out for someone else, what is your name and relation to the case?