Eagle County - COVID-19 Symptoms Report Form
Versión en español de formulario - https://docs.google.com/forms/d/e/1FAIpQLScQl0O4sbshCZU_vbpyAv1h6RsIEOvEjNKSGZccr1XdmNXJIA/viewform?usp=sf_link

Please fill out a single form for EACH person showing symptoms.

With community-level transmission of COVID-19 now confirmed in Eagle County, testing is not necessary or recommended for all patients and is being reserved for the most critical cases. It is important, however, that we continue to be able to track the spread of COVID-19 to align response resources in Eagle County and evaluate the strategies in place to decrease the spread of illness. We need your help by filling out this form. This information will help us greater clarity on areas impacted, types of symptoms being experienced. Most people who get COVID-19 will experience mild symptoms and not require direct medical care, however, information regarding any symptoms help public health response teams understand and track the spread of COVID-19 in Eagle County. While Please be aware that the Vail Hospital Emergency Department is available for life-threatening emergencies only.

If you are sick with mild symptoms and suspect it is COVID-19, please:
- Stay home. Isolate yourself and do not return to work, go to public places, or ride public transportation for 7 days after the start of your symptoms and fever free for 72 hours.
- Testing may not be recommended;
- Do not show up at testing facilities without a confirmed appointment;
- Separate yourself from other people in your home (minimum of 3 feet/1 meter);
- Avoid sharing personal household items and clean all “high touch” surfaces daily;
- Wear a facemask if encountering others;
- Cover your coughs and sneezes;
- Wash your hands frequently, and for at least 20 seconds;
- Monitor your symptoms for worsening illness;

If you have severe symptoms including feeling like you cannot breathe:
- Stay home;
- Call a primary care physician first (do not just show up);
- Do not show up at testing facilities without a confirmed appointment;
- If a medical emergency, call 911

Further instructions regarding isolation and homecare can be found at https://docs.google.com/document/d/16vYAgPWbKGQyens56eDri3pSnaqVzqqKh8OlgzbYKko/edit?usp=sharing and please call the Colorado Health Emergency Line (CO Help) at 1-877-462-2911 for specific questions.

For questions, contact COHELP@RMPDC.org and be sure to follow ecemergency.org for Eagle County-specific information on the COVID-19 response.
First Name
Your answer
Last Name
Your answer
Gender
Age
Do you have any pre-existing medical conditions such as heart disease, diabetes or lung disease?
Are you immuno-compromised?
What are your symptoms?
Check ALL that apply
When did your symptoms first start?
MM
/
DD
/
YYYY
What is your general location?
Contact - Phone
Your answer
Contact - Email
Your answer
Comments
In particular, note any observations such as loss of taste or smell
Your answer
Submit
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