COVID Intake Form
This form is used by the Noble County Health Department, Caldwell Ohio, to determine start of isolation dates for residents who are positive for Covid-19.  It will also help us recommend quarantine dates for your close contacts.
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Email *
Testing Location
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What is the expiration date on the home test? (if you took a home test.)
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First Name of Positive Case *
Last Name of Positive Case *
Street Address *
City *
State *
Zip Code *
What is the best phone number to reach you? *
Date of Birth *
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Race
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Ethnicity
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Are you submitting this form for yourself or a family member? *
Have you had any of the following symptoms since becoming sick with COVID? *
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When did symptoms first appear? If you did not have symptoms, enter your test taken date. Note: Minimum of 2 symptoms. For example, headache and sore throat, or cough and runny nose, etc *
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Over the last 24 hours, have your symptoms improved?
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Help us identify close contacts that you may have exposed who should be quarantined. Please let us know if they are aware that you are positive with COVID. A contact is considered anyone that you were around within 6 feet for more than 15 minutes, starting 48 hours prior to your illness onset (48 hours prior to test date if you are asymptomatic). Please List:
Where do you work or go to school? Please include grade and teacher or any other specific information. Are you involved in any extra curricular activities or sports?
What were the dates you were last at work, school or activities?
Were you vaccinated for Covid19?
Do you know how you may have been exposed?
Have you attended any Mass Gatherings?
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Have you recently traveled?
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Do you have any Health Conditions?
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Guardian's Name (if applicable)
Do you have a close contact that will need a work or school letter in order to quarantine?
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