Covid-19 Contact Tracing Survey

Name

Age

Phone

Email Address

Message

Are you currently experiencing or have you previously experienced any of the following symptoms? Check all that apply: (*) Loss of taste Loss of smell Are you currently experiencing or have you previously experienced any of the following symptoms? Check all that apply: (*) Loss of taste Loss of smellLoss of tasteLoss of smellShortness of breathCoughFever

When did you first start to experience these symptoms: (*) When did you first start to experience these symptoms: (*)TodayLess than one week ago1-2 weeks2-3 weeks3+ weeks ago

Have you been in close contact with someone who has been exposed?(*) Have you been in close contact with someone who has been exposed?(*) Yes No

How do you travel locally in Western New York? Check all that apply:(*) How do you travel locally in Western New York? Check all that apply:(*)BikePersonal bicyclePrivate vehiclePublic transitTaxi/Urber/LyftOther

If you chose “other”, please specify: (*)

Were you hospitalized? (*) Were you hospitalized? (*) Yes No

If yes, were you on a ventilator? (*) If yes, were you on a ventilator? (*) Yes No

Do you have any chronic medical conditions? Check all that apply: (*) Do you have any chronic medical conditions? Check all that apply: (*) Diabetes Asthma COPD Hypertension Coronary Artery Disease Heart Failure Other

If you chose “other”, please specify: (*)

How many people live in the home including yourself? (*)

Is anyone in the home experiencing any of the symptoms listed in Question 1? (*) Is anyone in the home experiencing any of the symptoms listed in Question 1? (*) Yes No

If anyone in the home has symptoms, can we contact them for a nurse evaluation and possible testing? (*) If anyone in the home has symptoms, can we contact them for a nurse evaluation and possible testing? (*) Yes No

What is the best way to contact these individuals for a nurse evaluation? Please provide any phone numbers or e-mails where we can reach out (*)