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COVID Questionnaire 2022-2023

Introduction

This form is for individuals who live in Dane County, Wisconsin who recently tested positive for COVID-19. Please complete the information below as soon as possible after your positive test. 

This survey is intended only for people who tested positive for COVID-19 (at a clinic or pharmacy, at school, at work, using a home test, etc.). 

Anything you enter in this survey will be viewable by Public Health Madison & Dane County even if you do not click the submit button at the end of the survey. All of your information will be kept confidential and will only be shared when it is necessary to protect the health of the public and as permitted by law.

This survey takes approximately 10 minutes to complete. Please plan to complete this survey in one sitting as you cannot save your progress and return to it later. 

If you would prefer to give this information over the phone with someone from Public Health, please call 608-243-0365 or email us at covidsurvey@publichealthmdc.com. We have staff answering the phone from 8:00 am - 4:30 pm, Monday through Friday.

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Thank you for your partnership when responding to COVID-19. 
1. Public Health Madison & Dane County (PHMDC) is covered by the Health Insurance Portability and Accountability Act (HIPAA). HIPAA is a set of federal requirements to ensure the privacy and security of an individual's protected health information. You can find PHMDC's Notice of Privacy Practices here: https://www.publichealthmdc.com/about/hipaa-open-records This Notice provides information about how we may use and disclose your protected health information and how you can get access to this information.
2. Does the person who tested positive for COVID-19 live in Dane County, Wisconsin? *This question is required.