Self Reporting of Coronavirus (COVID-19) Symptoms
Please fill out the form for EACH person.

This is a voluntary survey. Your participation in this survey helps your local public health agency gather important information about Coronavirus/COVID-19 symptoms in the San Luis Valley Region. This survey does not replace medical consultation with a health care provider or the nurse lines in our community.

With community-level transmission of COVID-19 now confirmed in the San Luis Valley, 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. We need your help by filling out this form. 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 the San Luis Valley.

For further information on COVID-19 symptoms go to covid19.colorado.gov. If you are experiencing symptoms that require medical care, please call your healthcare provider or a nurse call line at:

SLV Health Nurse Line: 719-589-2511, option 9
Rio Grande Hospital & Clinic: 719-657-4990

Thank you for taking the time to complete the survey!
Is this your first time taking this survey? *
What is your age? *
What is the gender you identify with? *
What county do you live in? *
What county do you work, attend school, or take your child to day care? (Check all that apply)
Do you have pre-existing medical condition? *
If you have pre-existing medical conditions, please list
Do you know if you have been around someone displaying symptoms of the Coronavirus/COVID-19 illness? *
What date were you around the person displaying symptoms?
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What symptoms are you experiencing? (check all that apply) *
Required
What date did your symptoms begin?
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How long have you had symptoms of Coronavirus/COVID-19? *
On a scale of 0-10 with zero (0) being no symptoms at all and 10 being the worst symptoms, how would you rate the severity of your symptoms? *
No symptoms
Worst possible symptoms
Have your symptoms changed since the last time you completed this survey? *
Have you contacted a Coronavirus/COVID-19 nurse line at a hospital or clinic? *
Have you been tested for the Coronavirus/COVID-19? *
If you have been tested for the Coronavirus/COVID-19, what are your test results?
Clear selection
Have you been hospitalized? *
If you have been hospitalized, were you admitted to the intensive care unit (ICU)?
Clear selection
Do you have any comments?
Submit
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