Contact Tracing Survey for Positive COVID-19 Individual
Thank you for choosing to complete our survey! Given the demand on public health resources, Flathead City-County Health Department is requesting your assistance in collecting the following information, which will help us in our response to COVID-19.
Form entries are encrypted, and your information will only be shared when it is necessary to protect the health of the public. Please submit one form for every positive test within your family.
Please complete this form within 24 hours of receiving the link, or someone from Flathead City-County Health Department will be reaching out to you by phone.
If you have questions and/or would rather complete your contact tracing interview by phone, please call us at (406) 751-8250.

Are you filling this out for yourself or someone else? Please submit one form for every positive test within your family.*
Myself Someone else
Name of Patient*
First Name Middle Name Last Name
Name of Patient*
First Name Middle Name Last Name
Name of Person Filling Out Form*
First Name Last Name
Relationship to Case*
Contact Number (If different than case)

Address
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code

Cell Phone*
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Email
We collect this information in case we need to confirm quarantine/isolation dates for yourself, your family, or other close contacts.

Where do you go to school?*
Have you notified your school that you have tested positive?
Yes No
What was the last day you went to school?
Month Day Year
Do you wear a mask at school?
Yes No
Do you participate in any school related sports or extracurricular activities?
Yes, more than one Yes No
What is the activity?
Please list the activities
What is the last date you participated in the activity?
Month Day Year
Date
What is the last date you participated in your first activity?
Month Day Year
Date
What is the last date you participated in your second activity?
Month Day Year
Date
What is the last date you participated in your third activity?
Month Day Year
Date

Have you been around anyone you've known to be positive for COVID-19?
Yes No
Do you have any close contacts that are HIGH RISK (i.e. immunocompromised, >65 years-old, those with heart conditions, underlying health conditions, healthcare worker, law enforcement, first responders, or those that work at or go to school) you may have exposed to COVID-19?*
Yes No
Do you have any close contacts that are not high risk?
Yes No
All close contacts who are not considered high risk will not be contacted by the Health Department. Please notify your close contacts about their possible exposure. Close contacts who have questions may call the COVID-19 Information Line at (406)751-8250 or visit our website at flatheadhealth.org for more information about COVID-19 quaratine recommendations.
Close Contacts

Have you ever received a COVID-19 vaccine?
Yes No
How many doses of COVID-19 (vaccine did you receive prior to onset of symptoms or, if you didn't have symptoms, your most recent positive test?
One (1) Two (2) Booster
What was the brand of your vaccine?
What was the brand of your booster?
Please either take a photo or submit an image of your vaccination card:
Take Photo

Recommendations for Stopping the Spread of Covid-19:
Following are the isolation recommendations (for individuals who test postivie) and quarantine recommendations (for close contacts). Close contacts are defined as those individuals who have been within 6 feet for 15 minutes or more with an individual who is confirmed positive for Covid-19.
Enter the day of symptom onset*
Month Day Year
Your release date will be on if you meet the below criteria
Criteria for release: Feel 50% better from your worst day, and 24 hours fever free without fever reducing medications. It is current CDC recommendation to get tested on day 5 of isolation. If you test positive, remain in isolation for an additional 5 days. If you test negative and meet the other criteria, you may release from isolation but continue to wear a mask through day 10.
Should be Empty:

Screening Tool