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2. Clear Creek County COVID-19 Symptom Self Reporting Form
   Please fill out a single form for EACH person showing symptoms. All personal information will remain confidential and will be HIPAA-protected. With community-level transmission of COVID-19 confirmed across Colorado, 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 Clear Creek County and evaluate the strategies in place to decrease the spread of illness in our community. This information will help evaluate areas being impacted and types of symptoms being experienced. Most people who get COVID-19 experience mild symptoms and do not require direct medical care; however, information regarding any symptoms help our public health team understand the virus. If you have symptoms, but are otherwise feeling ok, please self-isolate for 14 days and fill out this form. If you are symptomatic and worsening, please call (303) 670-7545 or your primary care physician. If it is an emergency, please call 911.
4. FIRST NAME*
5. LAST NAME*
7. PHONE NUMBER*
8. EMAIL
10. GENDER*

    1. MALE
    2. FEMALE
    3. PREFER NOT TO SAY
11. WHAT IS YOUR DATE OF BIRTH?*
    WHAT IS YOUR DATE OF BIRTH?
12. WHERE IN THE COUNTY ARE YOU LOCATED?*
    -- Select One --BAKERVILLEBENDEMEREBERTHOUD FALLSBLUE VALLEY ACRESBROOK FORESTCIRCLE KDOWNIEVILLEDUMONTFALL RIVER ROADFLOYD HILLGREYSTONEIDAHO SPRINGSGEORGETOWNECHO HILLSEMPIREEVANS RANCHLAWSONOLD SQUAW PASS SILVERPLUMEST MARYSUPPER BEAR CREEK WEST CHICAGO CREEKWITTER GULCHYANKEE CREEK

    Please select the general area that most closely represents where you are currently located
14. HOW MANY PEOPLE LIVE IN YOUR HOUSEHOLD?*
15. DO YOU HAVE MEANS OF TRANSPORTATION?*
    -- Select One --YES NO
17. HAVE YOU BEEN IN CLOSE CONTACT WITH SOMEONE THAT HAS BEEN CONFIRMED COVID-19 POSITIVE?*

    1. YES
    2. NO
    3. I DONT KNOW
18. ARE YOU IMMUNOCOMPROMISED?*

    Immunocompromised means you have a weakened immune system. this may be caused by certain diseases or conditions, such as AIDS, cancer, diabetes, malnutrition, and certain genetic disorders. It may also be caused by certain medicines or treatments

    1. YES
    2. NO
    3. PREFER NOT TO SAY
20. DO YOU HAVE ANY PRE-EXISTING CONDITIONS? SUCH AS DIABETES, HEART DISEASE OR LUNG DISEASE*

    1. YES
    2. NO
    3. PREFER NOT TO SAY
22. WHEN DID YOUR SYMPTOMS START?*
    WHEN DID YOUR SYMPTOMS START?
23. PLEASE SELECT THE SYMPTOMS THAT YOU ARE EXPERIENCING:*

    1. COUGH
    2. FEVER/CHILLS
    3. SHORTNESS OF BREATH
    4. TIREDNESS/FATIGUE
    5. MUSCLE ACHES
    6. RUNNY NOSE

    1. SORE THROAT
    2. LOSS OF TASTE OR SMELL
    3. NAUSEA/VOMITING/DIARRHEA
    4. NONE OF THE ABOVE
    5. OTHER

    If any of your symptoms are severe and you need immediate medical assistance, please call 911.
25. ADDITIONAL INFORMATION
    If you have additional pertinent information regarding your symptoms or potential exposure to COVID-19 that you would like to provide, please provide the information above.
27. DISCLAIMER
    By submitting this form you are consenting to be contacted by the Clear Creek County for follow-up regarding your submittal. Submitting this form does not guarantee you will receive a test COVID-19. Testing is extremely limited and is based on a tiered evaluation.
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29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

31. Submit Submit and Print

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