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.
First Name
Your answer
Last Name
Your answer
Gender
What is your age?
Your answer
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
On a scale of 1-10 how severe are your symptoms *
What is your general location?
What is your address?
Your answer
Contact - Phone
Your answer
Contact - Email
Your answer
Comments
Your answer
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