Case Intake Form

This form should be completed by residents of La Crosse County who have tested positive for COVID-19. We try to reach all cases by phone, but during times of high case volume, may not be able to reach you as quickly as we would like, or at all. We are asking ALL recent cases to complete this form, which will collect important information and provide you with guidance for yourself and your family. Your information will be kept confidential and nobody but the health department will have access to your responses. Thank you for your help.
Have you had a laboratory test that confirmed you had COVID-19?*
Yes, I have been diagnosed with COVID-19No, I have not yet been diagnosed with COVID-19
Are you currently living in La Crosse County?*
YesNo

Demographics
Legal Name*
First NameLast Name
Date of Birth*
MonthDayYear
Date
Phone Number*
Area CodePhone Number
Email
example@example.com
What is your race?
WhiteBlack/African AmericanAsianAmerican Indian/Alaskan NativeNative Hawaiian or other Pacific IslanderDeclines to answerOther
How many people live in your household, including yourself? If you live alone, enter "1."*
Enter name, relationship and phone number for all household members. Pleas also indicate if this person had or has symptoms of COVID-19. To enter additional people, press "Press to add another."*

Public Outings
Beginning from 2 days before your symptoms started (or when you were tested) through today, did you go in-person to any public locations such as a store, bar, restaurant, concert, conference, etc. that you have not already discussed elsewhere? Do NOT include work, school or other outings already discussed.*
Yes, I went to another public location that I haven't yet talked aboutNo, I have not been to a public location that I haven't yet talked about
Please list any locations you went to starting 2 days before your symptoms started (or when you tested) through today, including the dates and times you went to each establishment. Please be specific. If you aren't sure about a detail, provide as much information as you do remember. Some details are better than no details.*

Close Contacts
Beginning from 2 days before symptoms started (or if you have never had symptoms, 2 days before your test was conducted) through today's date, what people other than your household members were you in close contact with? Close contact could be someone who: (1) you had direct physical contact with (such as a hug, kiss, handshake, etc.), (2) you were within 6' of for at least 15 minutes or more, OR (3) was next to you when you were coughing, sneezing, spitting or singing for any length of time.*
Close contact with coworkersClose contact with friends/acquaintances who don't live in my householdClose contact with family who don't live in my householdClose contact with others not included aboveNo close contacts with anyone outside of household
Please enter the name, relationship and phone number for anyone other than members of your household with whom you had close contact. *
The La Crosse County Health Department tries to reach close contacts to provide important instructions about watching for symptoms, accessing testing, and reducing risk to themselves and others. We are not able to call all close contacts during times with high case numbers. For this reason, please notify your own close contacts. Information about how to do so - including a resource that will allow you to notify them anonymously - can be found here: https://lacrossecounty.org/covid19/if-you-have-been-exposed

Public Outings
Beginning from 48 hours before symptoms started (or if you have never had symptoms, 48 hours before your test was conducted) through today's date, have you been in person to any of the following locations?
I have not been to any public location during this time periodAny barAny restaurantAny grocery store (including Woodman's, Festival, Walmart, Target, Sam's Club, or others)Any gas stationPettibone BeachPettibone Boat ClubA salon, spa or barberAnother public location not covered above
Please list ALL locations you went to during this time period, including the dates and times you went to each establishment. Please be specific. If you aren't sure, provide as much information as you do remember. Some details are better than no details.*

This form is only for laboratory-confirmed positive cases of COVID-19 living in La Crosse County. If you have questions about an exposure or being tested, please visit https://lacrossecounty.org/covid19. If you have a question about something else, you can email us at covid19@lacrossecounty.org.

Isolation and Quarantine Instructions
Isolation Guidance for You (The Case)
How COVID-19 Spreads: COVID-19 is spread from one person to another through body fluids like saliva that come out of your mouth and nose when breathing, talking, singing, coughing or sneezing. It is very easy to spread, which makes it very important that you stay away from other people while you get better.
This is why you must stay in isolation. Isolation means that you do not leave you house, unless you need medical care. Do not go to work, school or daycare. If you live with other people, stay away from them as much as possible. Have food dropped off at your door if possible. If you need to go into parts of your home that are shared spaces, wear a mask at all times. If you use a common space such as a bathroom or kitchen, wipe down all surfaces with a cleaning product after you use it.
You must stay in isolation even if you feel better. Do not end your isolation until you are told it is safe to do so.
It will be safe for you to end isolation when:
- It has been at least 10 days since your symptoms began (or your test was conducted if you have not had symptoms), AND
- You have had no fever for 24 hours without using medication that would reduce the fever, such as tylenol or advil, AND
- Any other symptoms have been improved for 24 hours without using medication that would improve them.
When to Get Medical Help: If you experience a worsening of symptoms and/or find it difficult to breathe, you should seek medical care. If possible, call ahead to indicate that you are positive for COVID-19 so they can prepare. If you need to call 911, be sure to indicate that you need medical care but that you are positive for COVID-19 and are in isolation at your home so that they can help protect the ambulance workers.

Quarantine Guidance for Household Members
What Your Household Members/Close Contacts Should Do: Someone is considered "contagious" starting 2 days before their symptoms started or 2 days before their test was done if they hadn't yet developed symptoms. Anyone who has had direct contact with you for any length of time (a hug, kiss, high five, etc.), or who was within 6 feet of you for 15 minutes or more, while you were contagious is considered "exposed."
Anyone exposed who is not vaccinated and has not been diagnosed with COVID-19 in the past 90 days should quarantine. This means they stay at home and away from others so that if they are developing illness, they do not expose others. It is best to quarantine for 14 days after the most recent exposure; there are two ways to reduce quarantine to less time, which are addressed in detail here: https://lacrossecounty.org/covid19/if-you-have-been-exposed
Anyone exposed who is vaccinated or who has had been diagnosed with COVID-19 in the past 90 days does NOT have to quarantine. Vaccinated individuals who are exposed should wear a mask in public and when around other people, and should be tested 3 - 5 days after exposure. If symptoms develop or worsen for the individual in quarantine, they should isolate away from others and get tested immediately.
The La Crosse County Health Department wishes you a speedy recovery. Thank you for doing your part to keep our community safe.
Are you submitting this form for yourself, someone in your household, or a patient?*
SelfSomeone else in my householdI work for a healthcare institution and am completing this form with the patient or their legal guardianOther
Abiding by these instructions will help to keep you, your family and our community safe. By checking this box, you agree that you have read these instructions or had them explained to you.*
Yes, I have read these instructions or had them explained to me.
If you have any further information you would like to share, please add it here. Please note that we will not respond to questions through this form. If you have questions that require a response, please contact your provider or call/email the health department at covid19@lacrossecounty.org.

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Demographics

Symptom Onset

Source of Infection

Occupation and School

Public Outings

Close Contacts

Public Outings

Isolation and Quarantine Instructions

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