CMDHD Close Contact Survey

If you have tested positive for COVID-19, please use the below survey to report your close contacts. This will help save time during the case investigation for you and CMDHD staff.

1. Today's date (MM/DD/YYYY) *This question is required. This question requires a valid date format of MM/DD/YYYY.

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2. Your first and last name *This question is required.

3. Your birthday (MM/DD/YYYY) *This question is required. This question requires a valid date format of MM/DD/YYYY.

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4. Your phone number with area code. Example:123-456-7891 *This question is required.

6. Where were you tested?

7. When was your test done? (MM/DD/YYYY) This question requires a valid date format of MM/DD/YYYY.

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Please use the following grid to fill out your close contacts. For each contact you add, you must fill out all the information for the contact or else the survey will not submit.

“Close Contact” is defined as “those who were within 6 ft or less for more than 15 minutes total in a 24-hour period when the COVID-19 positive person was contagious. A person is contagious 2 days before symptoms appeared (or 2 days before testing positive if no symptoms), through the end of isolation.”

8. Close Contacts *This question is required.

Space Cell	First and Last Name	Phone Number with Area Code	Date of Last Exposure (MM/DD/YYYY)	Is this person a minor? (Enter Yes, No or Unknown)	What county does this person live in? (Put your own county if unknown)
Contact 1	Contact 1: First and Last Name	Contact 1: Phone Number with Area Code	Contact 1: Date of Last Exposure (MM/DD/YYYY)	Contact 1: Is this person a minor? (Enter Yes, No or Unknown)	Contact 1: What county does this person live in? (Put your own county if unknown)
Contact 2	Contact 2: First and Last Name	Contact 2: Phone Number with Area Code	Contact 2: Date of Last Exposure (MM/DD/YYYY)	Contact 2: Is this person a minor? (Enter Yes, No or Unknown)	Contact 2: What county does this person live in? (Put your own county if unknown)
Contact 3	Contact 3: First and Last Name	Contact 3: Phone Number with Area Code	Contact 3: Date of Last Exposure (MM/DD/YYYY)	Contact 3: Is this person a minor? (Enter Yes, No or Unknown)	Contact 3: What county does this person live in? (Put your own county if unknown)
Contact 4	Contact 4: First and Last Name	Contact 4: Phone Number with Area Code	Contact 4: Date of Last Exposure (MM/DD/YYYY)	Contact 4: Is this person a minor? (Enter Yes, No or Unknown)	Contact 4: What county does this person live in? (Put your own county if unknown)
Contact 5	Contact 5: First and Last Name	Contact 5: Phone Number with Area Code	Contact 5: Date of Last Exposure (MM/DD/YYYY)	Contact 5: Is this person a minor? (Enter Yes, No or Unknown)	Contact 5: What county does this person live in? (Put your own county if unknown)
Contact 6	Contact 6: First and Last Name	Contact 6: Phone Number with Area Code	Contact 6: Date of Last Exposure (MM/DD/YYYY)	Contact 6: Is this person a minor? (Enter Yes, No or Unknown)	Contact 6: What county does this person live in? (Put your own county if unknown)
Contact 7	Contact 7: First and Last Name	Contact 7: Phone Number with Area Code	Contact 7: Date of Last Exposure (MM/DD/YYYY)	Contact 7: Is this person a minor? (Enter Yes, No or Unknown)	Contact 7: What county does this person live in? (Put your own county if unknown)
Contact 8	Contact 8: First and Last Name	Contact 8: Phone Number with Area Code	Contact 8: Date of Last Exposure (MM/DD/YYYY)	Contact 8: Is this person a minor? (Enter Yes, No or Unknown)	Contact 8: What county does this person live in? (Put your own county if unknown)
Contact 9	Contact 9: First and Last Name	Contact 9: Phone Number with Area Code	Contact 9: Date of Last Exposure (MM/DD/YYYY)	Contact 9: Is this person a minor? (Enter Yes, No or Unknown)	Contact 9: What county does this person live in? (Put your own county if unknown)
Contact 10	Contact 10: First and Last Name	Contact 10: Phone Number with Area Code	Contact 10: Date of Last Exposure (MM/DD/YYYY)	Contact 10: Is this person a minor? (Enter Yes, No or Unknown)	Contact 10: What county does this person live in? (Put your own county if unknown)
Contact	Other: First and Last Name	Other: Phone Number with Area Code	Other: Date of Last Exposure (MM/DD/YYYY)	Other: Is this person a minor? (Enter Yes, No or Unknown)	Other: What county does this person live in? (Put your own county if unknown)
Contact	Other: First and Last Name	Other: Phone Number with Area Code	Other: Date of Last Exposure (MM/DD/YYYY)	Other: Is this person a minor? (Enter Yes, No or Unknown)	Other: What county does this person live in? (Put your own county if unknown)
Contact	Other: First and Last Name	Other: Phone Number with Area Code	Other: Date of Last Exposure (MM/DD/YYYY)	Other: Is this person a minor? (Enter Yes, No or Unknown)	Other: What county does this person live in? (Put your own county if unknown)
Contact	Other: First and Last Name	Other: Phone Number with Area Code	Other: Date of Last Exposure (MM/DD/YYYY)	Other: Is this person a minor? (Enter Yes, No or Unknown)	Other: What county does this person live in? (Put your own county if unknown)
Contact	Other: First and Last Name	Other: Phone Number with Area Code	Other: Date of Last Exposure (MM/DD/YYYY)	Other: Is this person a minor? (Enter Yes, No or Unknown)	Other: What county does this person live in? (Put your own county if unknown)
Contact	Other: First and Last Name	Other: Phone Number with Area Code	Other: Date of Last Exposure (MM/DD/YYYY)	Other: Is this person a minor? (Enter Yes, No or Unknown)	Other: What county does this person live in? (Put your own county if unknown)
Contact	Other: First and Last Name	Other: Phone Number with Area Code	Other: Date of Last Exposure (MM/DD/YYYY)	Other: Is this person a minor? (Enter Yes, No or Unknown)	Other: What county does this person live in? (Put your own county if unknown)
Contact	Other: First and Last Name	Other: Phone Number with Area Code	Other: Date of Last Exposure (MM/DD/YYYY)	Other: Is this person a minor? (Enter Yes, No or Unknown)	Other: What county does this person live in? (Put your own county if unknown)
Contact	Other: First and Last Name	Other: Phone Number with Area Code	Other: Date of Last Exposure (MM/DD/YYYY)	Other: Is this person a minor? (Enter Yes, No or Unknown)	Other: What county does this person live in? (Put your own county if unknown)
Contact	Other: First and Last Name	Other: Phone Number with Area Code	Other: Date of Last Exposure (MM/DD/YYYY)	Other: Is this person a minor? (Enter Yes, No or Unknown)	Other: What county does this person live in? (Put your own county if unknown)