Skip survey header

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.
This question requires a valid date format of MM/DD/YYYY.
calendar
This question requires a valid date format of MM/DD/YYYY.
calendar
7. Which of the following best describes you? Please check all that apply. *This question is required.
  • * This question is required.
This question requires a valid date format of MM/DD/YYYY.
calendar
10. Do you have any COVID-19 symptoms?

If you have chest pain, shortness of breath, wheezing, difficulty breathing, bluish lips/face or confusion seek medical attention immediately!
This question requires a valid date format of MM/DD/YYYY.
calendar
12. Have you let the employer or school know of the positive test?

(If not, we encourage you to do so for the safety of the other workers and students). 
13. Do you have children who attend school? *This question is required.
Are there other COVID-19 positive people in the household besides you* in the home?

*Or besides your child if you are a parent filling this out for a child. *This question is required.
14. Close Contacts: Were you close to anyone for more than 15 minutes 48 hours before you tested positive/had symptoms up until you began to isolate yourself? This includes household members. If you listed children in the household in school, please add them to this close contact list. 
  *This question is required.
To identify others at risk of COVID-19, we need a list of all your close contacts from 48 hours prior to when your symptoms started/when you tested up until you isolated yourself from others. 

These are people within 6 feet for more than 15 minutes when you were contagious. Think of work, school, and your household - including children.

When the health department calls close contacts, we only say that they are a close contact - we do not give them your name. 

Close contacts must follow quarantine guidelines. Individuals can leave quarantine at 10 days if they self-monitor for symptoms and wear a mask indoors around others. Even if the close contacts test negative, they must complete the full 10 days of quarantine.
Space Cell Name (first & last)Date of last contact with the positive personPhoneIs this close contact a minor (under the age of 18)?County of residence (if known)Does this person live with you?
Close Contact *This question is required
Close Contact
Close Contact
Close Contact
Close Contact
Close Contact
Close Contact
Close Contact
Close Contact
Close Contact
17. Would you like someone from the health department to still call you after you have submitted this survey? *This question is required.