COVID-19 Exposure Reporting Form
IF THIS IS A MEDICAL EMERGENCY, PLEASE CALL 911 OR SEEK MEDICAL ATTENTION.

REQUEST: If you are a resident of La Crosse County, WI, and know that you may have been in "close contact"* (see below) in the past 14 days with someone who has been diagnosed with COVID-19, and *have not already been in contact with the La Crosse County Health Department*, please use this form to share information with us.

*WHAT DOES "CLOSE CONTACT" MEAN: Close contact is defined by the CDC as: (1) being within approximately 6 feet of a COVID-19 case for a prolonged period of time; can occur while caring for, living with, visiting, or sharing a health care waiting area or room with a COVID-19 case – or – (2) having direct contact with infectious secretions of a COVID-19 case (e.g., being coughed on).

WHAT YOU SHOULD KNOW: If you did have close contact in the past 14 days with an individual who tested positive for COVID-19, it is still very possible that your risk is low. DO NOT PANIC. Our recommendations are based on a desire to be overly cautious and conservative in order to protect you, your family and our community.

WHAT YOU SHOULD DO: If you believe you had close, direct contact with someone who was diagnosed as having COVID-19, we would recommend that you remain in home quarantine for 14 days following the day AFTER your last contact with the positive case. For those 14 days, pay attention to your symptoms. If you develop any of the following symptoms, you should alert your healthcare provider by phone and remain at home in isolation. If the symptoms become severe, such as you experience difficulty breathing or shortness of breath, you should seek medical care but *let the healthcare provider or institution know you are coming BEFORE you arrive.* CALL AHEAD.
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What is YOUR name? *
What is YOUR phone number? Please include area code. *
What is your email address?
Do you think that you or a member of your household had close contact in the past 14 days with someone who has been diagnosed with COVID-19? *
The following questions pertain to whoever was in close contact with a positive case, whether that is you, someone else, or both.
Who was in close contact with a positive case of COVID-19 in the past 14 days? SELECT ALL THAT APPLY.
If you are reporting a close contact for someone else, please share their name and phone number (if applicable) here.
Where did this contact take place?
On which dates did this contact take place?
What was the nature of the contact? For example, what type of contact was it, how long did the contact last, etc.?
In what county does this person(s) live? SELECT ALL THAT APPLY.
In what county does this person(s) work? SELECT ALL THAT APPLY.
Do YOU currently have any of the following symptoms? SELECT ALL THAT APPLY. *
Required
IF YES: When did your symptoms start?
IF REPORTING CONTACT FOR SOMEONE ELSE: Does this other person(s) currently have any of the following symptoms? SELECT ALL THAT APPLY. *
Required
IF YES: When did this individual's symptoms start?
Are you, or any member(s) of your household who had this potential exposure, employed by a healthcare institution? SELECT ALL THAT APPLY.
IF YES: What healthcare institution do you/this individual work in?
If there is any other information you would like us to be aware of, please share that information here.
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