CSKT Tribal Health-COVID-19 and INFLUENZA Self Report Form
In order to assist Tribal Health Public Health in monitoring the amount of COVID-19 and Influenza A and B that we have circulating in the community, we are asking for your assistance with self reporting positive home tests. Please fill this form out completely to report a positive COVID-19 test or a positive Influenza A or Influenza B. Each positive individual in the household needs to have a form completed. If requested, you will receive a phone call from a Tribal Health nurse or other appropriate staff.
Name of positive individual
First Name
Last Name
If reporting for a minor, please tell us your name
Birth Date of positive individual
-
Month
-
Day
Year
Date
Gender
Male
Female
Prefer not to respond
Other
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date tested positive for COVID-19
-
Month
-
Day
Year
Date
Date tested positive for Influenza A
-
Month
-
Day
Year
Date
Date tested positive for Influenza B
-
Month
-
Day
Year
Date
Where were you tested?
If you were tested at a hospital/clinic/pharmacy/etc, do you know what kind of test result you received?
Rapid
PCR
I don't know
I did a home test
What is your race?
Asian
Black
White
American Indian / Alaska Native
Native Hawaiian / Other Pacific Islander
Unknown
Other
What is your ethnicity?
Hispanic/Latino
Non-hispanic/Latino
Not specified
Have you been hospitalized for COVID or Influenza since testing positive?
Yes
No
Have you seen a doctor since testing positive for COVID or Influenza?
Yes
No
Do/did you have symptoms? (symptoms may include cough, sore throat, congestion, fever, chills, fatigue, headache, loss of taste/smell, body aches, nausea, vomiting, diarrhea)
Yes
No
Not sure
If you have/had symptoms, what date did they start?
If you had symptoms, what date did they resolve?
Were you a close contact to someone that was diagnosed or tested positive for COVID-19 or Influenza?
Yes
No
Not sure
Check the symptoms that you had/have during the course of your illness.
Fever >100.4
Subjective fever (felt feverish)
Chills
Muscle aches
Runny nose
Sore throat
Cough (new onset or worsening if you have a chronic cough)
Shortness of breath
Nausea or vomiting
Headache
Abdominal pain
Diarrhea (more than 3 loose/looser than normal stools in 24 hours)
None
Other
Do you have any of these pre-existing medical conditions or risk behaviors?
Diabetes Mellitus
Hypertension
Severe obesity (BMI greater than 40)
Cardiovascular disease
Chronic renal disease
Chronic liver disease
Chronic lung disease
Other chronic diseases
Immunosuppressive condition
Autoimmune condition
Current smoker
Former smoker
Substance abuse/misuse
Disability (neurologic, neurodevelopmental, intellectual, physical, vision or hearing impariment)
Psychological/psychiatric condition
None
Do you attend school or work at a school or university? If so, which school?
Are you a healthcare worker? If so, where do you work?
Do you need a letter for work/school?
Would you like a nurse to contact you?
If you had a home test:
What do I do now?
Please note, if you asked for a letter, it will be mailed to the home address you provided. You can expect your letter in 2-4 days following submission of this form. Isolate yourself from all people until you are fever free without the use of fever reducing medication for 24 hours AND your symptoms are improving. For COVID infection it is recommended that you wear a mask when around others for a total of 10 days from symptom onset or positive test, even in your own home. Notify all of your close contacts of the need to monitor for symptoms and be tested if symptoms develop. Contact your local public health nurse at 406-745-3525 with questions or concerns. Thank you.
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