Gunnison County COVID - 19 Symptoms Self Report Form
Versión en español de formulario -
https://docs.google.com/forms/d/e/1FAIpQLScBxZ4XRJSYiLCPrW7AiY5Oor8EvTlTchR2aFmwemZeqEx52A/viewform?usp=sf_link
Please fill out a single form for EACH person showing symptoms.
All of your personal information will remain anonymous, and is there to allow our Health and Human Services staff to monitor you.
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 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 Gunnison County. Please be aware that the Gunnison Valley Hospital Emergency Department is available for life-threatening emergencies only.
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.
* Required
First Name
Your answer
Last Name
Your answer
Gender
Female
Male
Prefer not to say
What is your age?
Your answer
Do you have any pre-existing medical conditions such as heart disease, diabetes or lung disease?
Yes
No
Prefer not to say
Are you immuno-compromised?
Yes
No
Prefer not to say
What are your symptoms?
Check ALL that apply
Headache
Fever
Shortness of breath
Chills
Muscle aches
Runny nose
Sore throat
Cough
Lost sense of taste/smell
When did your symptoms first start?
*
Date
On a scale of 1-10 how severe are your symptoms
*
1
2
3
4
5
6
7
8
9
10
What is your general location?
Almont
Cimarron
Crested Butte
Crested Butte South
Curecanti
Gunnison
Lake City
Marble
Mount Crested Butte
Ohio City
Parlin
Pitkin
Powderhorn
Sargents
Tin Cup
White Pine
Sapinero
Somerset
What is your address?
Your answer
Contact - Phone
Your answer
Contact - Email
Your answer
Comments
Your answer
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