Self Report Form-Symptoms Resolved
Please fill out a single form for EACH person. Please only fill this form out if you have reported symptoms previously with our Self-Report form.

With community-level transmission of COVID-19 confirmed in Gunnison County, testing 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 Gunnison County. As we progress through this pandemic it is important for us to understand how many people that have previously self-reported symptoms have seen those symptoms resolve themselves.

If you are symptomatic, but otherwise ok, please self-isolate for 10 days and self-report at www.gunnisoncounty.org/covid19
If you are symptomatic and worsening, please call the call center. 970-641-7660
We ask that you not show up to the screening site until you call first.
If it is an emergency, please call 911.


Be sure to follow https://www.gunnisoncounty.org/938/Coronavirus-COVID-19 for Gunnison County-specific information on the COVID-19 response.
First Name
Last Name
Gender
Clear selection
What is your age?
Do you have any pre-existing medical conditions such as heart disease, diabetes or lung disease?
Clear selection
Are you immuno-compromised?
Clear selection
What are your symptoms?
Check ALL that apply
When did your symptoms first start? *
MM
/
DD
/
YYYY
On a scale of 1-10 how severe were your symptoms *
What is your general location?
Clear selection
When did you recover from your symptoms? (RECOVERY defined as resolution of fever without the use of fever-reducing medications for 72 hours and improvement in respiratory symptoms (e.g., cough, shortness of breath); and, At least 10 days have passed since symptoms first appeared.)
MM
/
DD
/
YYYY
Street Address?
Contact - Phone
Contact - Email
Comments
Submit
Never submit passwords through Google Forms.
This form was created inside of ICELab. Report Abuse