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COVID-19 Case Report
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Reported By:
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Individual's First and Last Name
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Description (symptoms, possible exposure, significant travel, etc.)
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If tested for COVID, date tested
MM
/
DD
/
YYYY
If tested for COVID, date results received.
MM
/
DD
/
YYYY
COVID test results
Negative
Positive
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If COVID positive, when did you first experience symptoms?
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DD
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YYYY
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