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Butte County COVID-19 Community Monitoring Form
*The following form will be used for monitoring symptoms. Zero lab tests or cases will be tracked here. All data submitted will be confidential.
COVID-19 Symptoms Report Form
Please fill out a single form for EACH person showing symptoms.
Gender
If female are you pregnant?
Age
Ethnicity
Do you have any pre-existing medical conditions such as heart disease, diabetes or lung disease (other than asthma)?
What are your symptoms?
When did your symptoms first start?
MM
/
DD
/
YYYY
What is your general location?
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