Contact Investigation Form

Contact Investigation Form
This form should be used to interview exposed contacts of confirmed cases.
Assignment or Interview
Contact Assignment
Only complete this part if you are assigning a new contact to an investigator.
Name
First NameLast Name
Phone Number
Format: (000) 000-0000.
Contact Exposed to Which Patient
Last Day Exposed
MonthDayYear
1
Exposure Site
Notes
Your Name
This is the person assigning a case.
Case Assignment
Interviewer Name
Date of Interview
MonthDayYear
2
(Call the patient) Hello, my name is [insert name here] and I am calling from Pitkin County Public Health. Am I speaking with [insert patient name here]? Before moving forward, can you please verify your date of birth to ensure I am speaking with the right person? Thank you for verifying that. I am calling because we have received notification that you have been exposed to someone who has tested positive for COVID-19. Have you been made aware of this information yet?
Okay, thank you. When we receive word that someone may have been exposed to COVID-19, we, at the health department, call to determine the nature of your exposure by asking you a few questions. So, do you mind if I ask you a few questions?
Okay, first, I would like to verify and get some basic demographic information from you.
Patient Date of Birth
MonthDayYear
3
Patient Sex
Patient Ethnicity
Patient Race
Patient Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
County of Residence
Patient Email Address
example@example.com
Employer
Occupation
Days Worked Last 2 Weeks
Do you remember being around anyone who has been ill recently? If so, please explain.
Now, I'd like to ask you about any symptoms you may be experiencing or have experienced recently. (Provide the person with a date to start at, which would be two days after they were exposed). Since [insert date], let me know if you have experienced any of these symptoms even if they were mild or you only had them for a short period of time.
FeverSubjective FeverCough (new onset or worsening of chronic cough)Sore ThroatShortness of BreathChillsMuscle AchesRunny NoseNausea or VomitingHeadacheAbdominal PainDiarrheaLoss of Taste and/or SmellNo Symptoms/AsymptomaticRefused to Respond/UnknownOther
Patient's Symptom Onset
MonthDayYear
This is the date that the patient developed their first symptom.
Did the patient report ANY symptoms at least two days after exposure?
Based on the information we have, we will need you to quarantine yourself. We are requiring this because it is likely you were exposed to COVID-19, you may have the virus, and this is the best method we currently have to ensure infection does not continue to spread.
Until we get more information, we need you to quarantine until
MonthDayYear
14 days from the date of exposure.
This means you must stay at home and do not leave the house for any reason other than emergency medical care. We will send you a letter that you can use to send to your employer, if needed, that will inform them that you have been asked to quarantine. Unfortunately, even if your test comes back negative, we will still require you to quarantine until the date I just provided you. If you test positive, depending on your symptoms, you may be able to end quarantine early, but we will discuss that after your results come back. Since you have symptoms, we will also need you to be tested. Testing is generally done by your doctor. Do you have a primary care physician in the area?
Primary Care Physician
Please call your doctor today to schedule a test. If your doctor does not perform COVID-19 testing, have him/her write you an order to be tested at Aspen Valley Primary Care. In general, it is best for you to wait two days after you develop symptoms to get tested. That is when the test is most reliable. So, please request from your doctor that you get tested at least two days after you developed symptoms. When your test has been scheduled, please text or call me back immediately with the date and time of your appointment.
Given that quarantining can be burdensome, the county may be able to provide financial and food assistance during this time if needed. With that said, would you like for us to make a referral to the county on your behalf to help you while you isolate?
County Referral
In order to request testing, you will need to call Aspen Valley Primary Care. Let me know when you're ready to write down their phone number: (970) 279-4111. In general, it is best for you to wait two days after you develop symptoms to get tested. That is when the test is most reliable. So, please request from your doctor that you get tested at least two days after you developed symptoms. When your test has been scheduled, please text or call me back immediately with the date and time of your appointment.
Given that quarantining can be burdensome, the county may be able to provide financial and food assistance during this time if needed. With that said, would you like for us to make a referral to the county on your behalf to help you while you isolate?
County Referral
Was the patient potentially exposed to the case patient for either >15 minutes within a 6 foot proximity while masked or were the patients in close proximity to one another without masks at any time during the case patient's infectious period?
COVID-19 Exposure
So, based on the information we have received, we will need you to quarantine until [14 days from exposure]
MonthDayYear
4
This means you must stay at home and do not leave the house for any reason other than emergency medical care. We will send you a letter that you can use to send to your employer, if needed, that will inform them that you have been asked to quarantine. Unfortunately, even if your test comes back negative, we will still require you to quarantine until the date I just provided you. If you test positive, depending on your symptoms, you may be able to end quarantine early, but we will discuss that after your results come back. Given that quarantining can be burdensome, the county may be able to provide financial and food assistance during this time if needed.
County Referral
With that said, would you like for us to make a referral to the county on your behalf to help you while you isolate?
At this time, we will not be asking you to quarantine as it is does not appear that you had a true exposure to the virus based on what you told us. We will, however, need you to closely monitor yourself for symptoms until [14 days from date of exposure]. So, each morning, please ensure you do not have any of the symptoms I asked you about during this interview. If you develop any of these symptoms up until [14 days from date of exposure], please immediately isolate yourself at home and call our hotline at (970) 429-6186. Do you have any additional questions for me? [Answer, if any] We will be sending you an email with some additional information, including the number to our hotline should you any additional questions or concerns. Thank you for taking the time to speak with me today.
Interview Complete
AFN Referral Complete
Interview Complete
Notes
Should be Empty: