Notification of Exposure: A Contact Tracer’s Guide for COVID-19

Overview

Notification of Exposure: A Contact Tracer's Guide for COVID-19

A successful notification of exposure allows for an exchange of information with the person (contact) exposed to COVID-19 and offers an opportunity to answer questions and provide referrals for testing, medical evaluation and other necessary support services.  The goals of this interaction are to inform the person that they may have been exposed to COVID-19, assess their medical condition and other risk factors, and gather information for continued monitoring and support. Developing trust and a warm, empathetic rapport, while maintaining a professional relationship, is key to providing effective support and collecting accurate information to inform the next steps in the contact tracing investigation. State and local public health officials will decide how to implement these activities and how to advise specific people, or groups of people, to be tested.

Principles for interactions with a person exposed to COVID-19:

  • Ensure and protect confidentiality.
  • Demonstrate ethical and professional conduct.
  • Create a judgement-free zone.
  • Be open-minded (everyone has a unique story).
  • Be attentive and respectful.
  • Be aware of your own bias (cultural humility).
  • Establish open dialogue and pause often to listen.
  • Ask open-ended questions.
  • Use reflective listening techniques.
  • Use culturally and linguistically appropriate language.
  • Employ critical thinking and problem solving.
  • Adapt to address concerns/information that naturally arise during conversation.
  • Identify areas of need and link to appropriate resources.
  • Don’t overstep or overpromise.
  • Set the stage for ongoing communication and support during quarantine.

Language is important. It sets the stage to build rapport with contacts and opens the door to honest dialogue. It is critical to establish open communication with people exposed to COVID-19 so that they feel comfortable expressing what they need in order to safely self-quarantine and seek help if they develop symptoms. If supportive statements and genuine concern are combined with active listening and open-ended questions, powerful information can be gathered to interrupt the spread of the virus. Asking open-ended questions prompts a dialogue and elicits more detailed information, and often the information is helpful in learning more about the person and their circumstances.

This document provides suggested communication approaches for Local Health Jurisdictions (LHJs) to consider as they craft their own scripts for contact tracers. Local scripts may need to be modified to address local needs, including but not limited to highlighting available resources, cultural nuances, exposure sites, and the capture of epidemiological data. Interviewers should use what is helpful and the best fit for the interaction; all questions or statements may not be required and additional probing questions may be necessary. Programs are encouraged to share best practices in framing and phrases as they are identified.

Aims: Introduce themselves and establish credibility. Verify contact information, build rapport, address confidentiality

Intro

  • May I speak with [respondent name]?
  • Am I speaking with [respondent name]?
  • Hello, this is [interviewer’s name stated and spelled out]. I am a/an [title] with the , calling for {respondent name].
  • [For minors] Who is their/your parent/guardian? How can I reach their/your parent/guardian?
  • What language(s) do you feel most comfortable speaking?
  • I am following up with you to discuss an important health matter. This call is private and intended to assist you with this matter. Is now a good time to talk privately? If not, what time works best for you?
  • If you are not available now, let’s schedule a time to talk. We have some important health information for you and want to be sure that you can get the referrals and resources you may need, and answer questions that you may have.

Verifying Identity

  • It is important for me to ensure that I am speaking with the right person. What is your full name and date of birth, please?
  • Before we get started, I would like to make sure that the information we received is correct. Please spell your full name. And what name do you go by/what do people call you? What would you like me to call you?

Reason for Call

  • It has come to our attention that you may have been recently exposed to COVID-19.
  • Has anyone already talked to you regarding your possible COVID exposure? If so, who? Some of the early symptoms of COVID-19 can look similar to other illnesses, and sometimes, people have no symptoms. You may have been exposed by someone who had no idea they were sick.
  • In order to stop COVID-19 from spreading in the community, we follow up with people who have been exposed, and work with them to make sure they get care if they need it. We also ask them to watch for symptoms and stay separate from others so that they don’t spread it by accident, if they start to get sick.
  • Someone cared enough about you to make sure that you were able to get this information, and the testing and medical care necessary to keep you, your family and others healthy.
  • This type of information can be overwhelming for many people. We want to work with you to help you get the care that you may need.
  • [if asked] The name of the person who tested positive is confidential. I cannot tell you their name, just like I cannot share your personal information with others.
  • I would like to review some important information and questions with you so we can provide you with support and work together to stop the spread of COVID-19 in our city/county/town.

Confidentiality & Privacy

  • Before we go into detail, I want to be sure you understand that everything we discuss is confidential. This means that your personal and medical information will be kept private and only shared with those who may need to know, like your health care provider. What questions do you have about your privacy/confidentiality?

Other

  • What questions can I answer for you before we start?

Aims: Verify demographic and locating information; establish the best way to reach the contact; obtain information on residence, work and emergency contact numbers.

Intro

If it’s OK with you, I’d like to start with a few questions to make sure that the information that we have is correct and also find out the best way to contact you.

Demographics

  • I know that I already confirmed your name. Are there any other names that you go by or your medical information may be under (e.g., maiden name)?
  • What is your gender?
  • What is your race?
  • What is your ethnicity? Are you of Hispanic origin?
  • Do you have a tribal affiliation? If so, which tribe?
  • [For women] Are you currently pregnant? (If yes) how far along are you (months, weeks)?
  • What is your [any other locally specific socio-demographic information]?

Locating and Contact Information

  • Where do you stay (or live)? What is your address?
  • Where else may have you lived (or stayed) during the past month?
  • [If person indicates that they ‘live on the street’] If you don’t have a regular place that you stay, where is it best to find you? (probe for cross streets, site description, name of building/shelter, where they receive mail, etc.)
  • Who else lives with you? (Who else stays at that address?)
  • How many people regularly stay at that address?
  • What is your cell phone number? Who else might answer that phone?
  • What is the best number for me to reach you? Who else might answer that number?
  • What is the best time to contact you?

Work

  • What do you do for work (name, location(s), hours)?
  • Tell me about your work. What do you do there?
  • Where do you work (name, location(s), hours)?
  • Where else do you work (name, location, hours)?
  • What other things do you do to earn money besides the job you just described?
  • When was the last time you were at work?
  • How does your workplace protect people from COVID-19 (e.g., providing masks for employees, establishing social distancing space with markers for employees/customers, “screening” for temperature and symptoms upon entry, putting up clear plastic dividers between employees or employees and customers, providing hand sanitizer, posting signs about COVID-19 and how to prevent it, increasing cleaning and disinfection.)
  • Some workplaces have different requirements for people who are exposured to COVID-19. For example:
  • health care workers, first responders and other critical infrastructure workers
  • employees in long-term nursing facilities, assited living facilities, group homes, mental health hospitals, correctional facilities, homeless shelters
  • and employees who work in large work areas, like factories and food processing plants
  • Does your role at your work or work setting fall into any of those categories? If so, we can discuss in more detail about what this means after we talk about your health and what support you may need.

Emergency Contact

  • In case of an emergency, if I could not reach you, who would I call? What is their number? What is that person’s relation to you?

Aims: Gain insight regarding patient’s knowledge of COVID-19; provide disease-specific information; assess potential COVID-19 symptoms and underlying health conditions; make referrals for medical care as appropriate.

Intro

  • I would like to take a few minutes to talk with you about the virus, check in on your health and discuss how to keep you as healthy as possible and support you during this time. How does that sound?

Disease Comprehension

  • First, what do you know about COVID-19?
  • What have you heard about COVID-19? (e.g., online, in the news, from friends, family or coworkers)
  • There is a lot of information out there about COVID-19, and sometimes it is hard to know what is fact and what is myth. What questions do you have for me about the virus?
  • Some basic facts about COVID-19 are [Note: Recommend both covering this information verbally and providing a handout via email, hardcopy]:

Symptoms of COVID-19

  • COVID-19 can cause a variety of symptoms. Some COVID-19 symptoms can seem like a common cold and others are more severe and sometimes people have no symptoms. Please let me know if you have had any of the following symptoms and when they started. [Note to Contact Tracer: See Appendix A for a table of COVID-19 symptoms, with space to indicate onset and duration. This Information can help to identify contacts who will need to be referred for medical evaluation due to current symptom presentation, and also allow for discussion of which symptoms the contact should be “on the lookout” for during quarantine.]
  • What symptoms were you having? [Note to Contact Tracer: See Appendix A for a table of COVID-19 symptoms, with space to indicate onset and duration.] When did those symptoms start?
  • [If patient states any of the emergency warning signs (e.g., trouble breathing, persistent pain or pressure in the chest, new confusion, inability to wake or stay awake, or bluish lips or face) refer them for emergency medical attention immediately!]
    • From what you are describing, it sounds as though you should be seen by a health care provider to further evaluate your symptoms as soon as possible. You need to call 911 or go to the emergency room. Wear a cloth face covering when an ambulance comes to get you and during your visit to the medical provider. Let them know that you received a call from the health department to notify you of possible exposure to COVID-19.
  • [If yes to symptoms] If you have any of these symptoms, have you gone to see the doctor/ER/health care provider (yes/no).
    • [If yes, contact already seen by health care provider]
      • What happened at the visit to your health care provider? Did you talk about COVID-19?
      • Did your doctor/nurse/health care provider test or diagnose you with COVID-19? What type of test did you receive? What were your test results?
      • How are you feeling now?
      • We want to make sure that we can best support you, so we will have a health department liaison follow-up with you to discuss your health care visit and symptoms in more detail.
    • [If contact not yet seen by health care provider]
      • Given the symptoms you have described, it seems that you should be seen by a health care provider.
      • Who is your primary medical care provider? What is their office location and phone number? Would you like to reach out to them today or would you like us to have follow-up with you to help with a referral for testing and a medical assessment? What is the best number for them to reach you at today?
      • How will you get to your health care provider? Do you have a mask to wear during transport and while in the office? [NOTE: Discussing and problem-solving challenges, providing local resources is essential.]
  • [If no to symptoms] It is good that you have not noticed any symptoms yet. It can take between 1-14 days for COVID symptoms to show up, and in some instances people with COVID do not show any obvious symptoms, but they can still spread the virus. We don’t know yet if you have the virus or not. Let’s talk about some other risk factors for COVID-19 and then we can talk about next steps.
  • What questions do you have for me at this time about COVID-19?

Underlying Health Conditions and Other Risk Factors

  • Some other health conditions may impact how COVID-19 affects the body. Sometimes we may need to do extra monitoring for people who have other health conditions to be sure that we can get them help if they need it. Have you ever been diagnosed by your health care provider with any of the following:
    • Chronic lung disease?
    • Moderate to severe asthma?
    • Heart conditions (list the type of heart condition)?
    • A health condition that effects your immune system? This can be due to any number of things such as:
      • cancer treatment
      • bone marrow or organ transplantation
      • immune deficiencies
      • HIV or AIDS
      • prolonged use of corticosteroids and other medications that can weaken the immune system
    • Obesity?
    • Diabetes?
    • Chronic kidney disease? If so, are you undergoing dialysis?
    • Chronic liver disease?
    • Other health condition?
  • Some other health conditions may impact how COVID-19 affects the body. Tell me about other health conditions you may have. [If the local area is collecting data on specific co-morbidities, you may ask about those specific health conditions after asking this question.]
  • What medications do you take for this/these conditions?
  • What medication have you taken recently, either prescribed or over the counter? When did you start them? For how long have you taken them?
  • Other activities can increase the risk for complications from COVID-19, including smoking. Do you smoke or vape? [If yes] When is the last time that you smoked? Vaped?

If testing for COVID-19 is recommended

  • It is important to go in for testing as soon as possible. When will you be able to go for testing?
  • What challenges do you anticipate with getting in for testing? Difficulty with transportation to get to a testing site? Do you have other caregiver responsibilities, where you can’t leave someone alone? [NOTE: Discussing and problem-solving challenges, providing local resources is essential.]
  • [If contact states that they have already been tested] So you have previously been tested for COVID-19? Where? When? What were the results?
  • Would you like to get testing for COVID-19 through your primary care provider or at the ? We have a list of test sites available.  [Note: The first two question/statements should be modified to reflect locally relevant testing through primary care and other health care settings, local COVID-19 test sites, and health department resources.] Let’s talk about which one is most convenient for you. How will you get to the testing site?
  • It should take about days to get your test results back. Once we know those results we can determine the next steps.
  • If your test results come back positive, a health department liaison will follow up with you. A negative result will mean that you didn’t have COVID-19 at the time you were tested. But we don’t know if you will develop the virus during the next days or not, it is very important that you self-quarantine, starting today, to keep your family, household members safe and others in the community safe.

Other

  • What worries or concerns do you have that you would like to discuss? Who would you want to tell about your possible exposure to COVID-19?
  • What questions do you have for me at this time about COVID-19?

Aims: Discuss parameters and importance of quarantine recommendations; Assess patient’s concerns and resources to enable safe and healthy quarantine; Cooperatively identify potential areas for support and referral.

Quarantine Recommendations

  • Now, I’d like to talk with you about home quarantine, review the recommendations, and identify what you may need to support you and keep you and your family and other household members healthy. How does that sound?
  • Since we don’t know yet if you will develop COVID-19, you will need to self-quarantine for 14-days from the day when you were exposed to the virus. Self-quarantine means that you will have stay at home for days or until [date]. You should not go to work or out into the community to run errands or attend events. Ideally, you should stay in a separate part of the house from others who live with you, preferably in a bedroom by yourself, and use your own bathroom that no one else uses during this time. Specific instructions for quarantine are available on the CDC website.
  • Being on quarantine means that you will not be able to go to work or the grocery store or other places around town.
  • During the next , you will need to limit your interactions with people in your household, staying 6 feet (2 meters) away from them.
  • When interacting with others in your household, you should wear a cloth face covering over your nose and mouth to help protect others in case you’re infected but don’t have symptoms. Your caregiver may also wear a cloth face covering when caring for you. Children under age 2, or anyone who has trouble breathing, should not wear a mask.
  • If at all possible, you should avoid contact with people at higher risk for severe illness (unless they live in the same home and had same exposure as you), regularly wash your hands and following other measures outlined in the CDC guidance. If at all possible, stay in your room and have food, other necessities and recreational items left outside the door, to minimize your contact with others.
  • There are a number of preventive measures that you can put in place to protect your family and other household members, such as: wiping down shared spaces with appropriate cleaning products, keeping a separate set of dishes, silverware and glasses available for your use. I will send you information on how to clean and disinfect your home (for those sharing space with others).
  • It will be important to identify other people to assist you with daily life activities during self-quarantine. You will need to stay at home and therefore you will need others to support you in grocery shopping, picking up medications and caring for children and other family members during this time.
  • If you have pets, you should remain separate from them during self-quarantine, just as you would with other household members, and avoid direct contact, including petting, snuggling, being kissed or licked, sleeping in the same location, and sharing food or bedding. If possible, another person in your household should take care of the pets and should follow standard handwashing practices before and after interacting with the household animal. If you must care for your pet or be around animals while you are sick, wear a cloth face covering and wash your hands before and after you interact with them.
  • In accordance with the Americans with Disabilities Actexternal icon, service animals are permitted to remain with their handlers.

Assessing Concerns

  • What would self-quarantine look like for you?
  • What concerns do you have about the situation that I just described? [NOTE: Validating concerns, exploring solutions and offering support/resources (as appropriate) is essential.]
  • Does this sound like something that would be hard or easy for you? Why? What could you do or what support would you need to address the hardest parts?
  • What would be helpful for you to better understand or remember the instructions about home isolation?

Assessing Living Situation

  • It may be helpful to talk about what kind of support you might need during self-quarantine.
  • Let me just double check the address where you are staying (confirm address).
  • What does your living situation look like? (probe for type of living environment: single flat, apartment, house, group home, treatment facility, single room only hotel, condo, tent encampment, etc.)  How many rooms, bedrooms, bathrooms? Are there shared common areas (e.g. kitchen/dining room/living room/laundry/elevator)?
  • Tell me about the place where you live (prompts: house? Apartment?). Who lives there with you? What are their names/ages?
  • Who else stays there from time to time? When was the last time they were there? What are their names/ages?
  • How many children do you have? Where do they live?
  • What other children (under 18) are in the home? Who are their parents/guardians?
  • What is your living situation? Who else lives with you? What are their names, ages and relationships to you?
  • Would it be possible for you to have access to your own room and bathroom?
  • How safe do you feel in your current living situation? Have you ever felt threatened, been hit or hurt by someone who you live with? [If patient feels unsafe or answers yes to the second question] We have resources to support you
  • Is there an alternate place that you could stay?
  • Would you consider moving to an offsite location to support you and protect your family/household during your quarantine? If this were an option, what would be your concerns?

Assessing Other Supports

  • When you think about what I have just described, what comes to mind? What challenges do you see? What kind of support would you need to overcome them?
  • What challenges do you foresee with maintaining your health and your household during quarantine?
  • What do you think will be the hardest thing about quarantine? How will you deal with that?
  • Do you have access to fresh water and enough food?
  • Do you have access to a mask/face covering(s)?
  • How will you prepare your own food? Who can assist you with getting meals?
  • How will you get other household supplies (e.g., toilet paper, soap, etc.)?
  • What medications will you need to take? How long until your prescription needs to be refilled? What would home quarantine look like for you?
  • Who do you provide care for in your household? Children? Parents? Older person? Sick person? Is there someone else that can take on that role?
  • What pets or animals do you have in your household? What kind of supplies will you need for them during your quarantine? Is there anyone else who can take care of your pets or animals?
  • Who can assist you with support (e.g., getting meals and other household supplies) during home quarantine?
  • What will you do to get food and other essential items without leaving your house?
  • You may be off from work during home isolation or may be able to telework if that is a policy at your workplace and you feel healthy enough to continue working. How will you approach this discussion with your employer? Will you be getting paid sick leave from your employer?
  • What concerns do you have about the financial impact that home quarantine will have?
  • What concerns do you have about how home quarantine will affect your health and wellbeing? What do you think you can do or what support do you need to make a positive impact?
  • How do you think that you staying separate from them will impact your family? How do you think you will deal with that?
  • What assistance would be helpful for you?
  • What would support look like for you during this time?
  • There are support services available to assist you and your family with some of these tasks, let’s talk about which ones may be helpful to you.
  • What types of medical or other important appointments do you have scheduled over the upcoming weeks? Let’s see how we can work to support you with those.
  • What other supports might you need during your quarantine [or period]? Explore pdf icon[Note: Local resources should be listed and discussed.]:
    • Food
    • Childcare
    • Housing
    • Prescriptions
    • Non-COVID medical care
    • Support with stress, resiliency, mental health
    • Substance use treatment/support groups
    • Translation/interpretation
    • Assistance caring for someone else
    • Transportation
    • Disability accommodations
    • Financial assistance
    • Communication (cell service, internet)
    • Other

Release from Quarantine

  • The amount of time that you will be on self-quarantine is 14 days from the last day of exposure to COVID-19. Public health workers and your health care provider will be talking with you to make sure that you have the testing or approval necessary to be released from self-quarantine.

Release from Quarantine: Special Circumstances

  • In some instances, health care personnel and other critical infrastructure workers (without symptoms) have exemptions from the standard quarantine procedures, in order to ensure continuity of essential operations. Let’s talk about whether or not this is relevant in your situation [insert locally specific guidance here].

Disclosure Coaching

  • Given that there will need to be a plan for social distancing and also supports set in place to assist you while you are on home quarantine, it will be important to think about how to talk about this with those in your household.
  • Who in the household are you planning on telling about your exposure to COVID-19? What do you expect that discussion to look like? [Offer coaching if appropriate] Would you like support in telling them about your exposure? Would you like to arrange for a 3-way call, so that I can be available to answer questions that may come up?

Other

  • What other concerns (e.g., someone may be sick, someone may have a pre-existing health condition) do you have regarding the home quarantine instructions, the members of your household or being separated from them during self-quarantine? Let’s discuss some steps to take that may address your concern(s).
  • Who in your household has been sick recently? (If yes, what type of symptoms, when started for how long)
    • Have they gone to the doctor or to get tested for COVID-19? (If yes, when and where, results?)
  • What questions or concerns do you have about self-quarantine that we have not covered?

Aims: Cooperatively establish a plan for daily monitoring of health status; Discuss importance and develop a clear plan to access medical services should the need arise.

Intro

  • I’d like to talk with you about setting up a plan for you to monitor your health each day so that we can get you help if you need it. Shall we continue?
  • We would like to work with you to set up daily check-ins, so that we can make sure that you are okay. This way if you start to develop symptoms, we can work together to get you the medical care that you need.
  • Let’s talk about setting up daily check-ins in order to monitor your health by taking your temperature every day and keeping track of how you feel. There are a few things that we can provide to help you monitor your symptoms.

Monitoring Agreements & Tools

  • Some of the more basic items to help you monitor your symptoms and keep you and those living with you safe include a washable cloth face covering, gloves, thermometer, 60% alcohol-based hand sanitizer, soap, EPA-registered household disinfectantexternal icon
  • We have set up to help with communication for daily check-ins, let’s get you registered for that system. We encourage you to register for [email/test messaging/other automated system] which is quick, private, and allows you to provide your information on a schedule that works for you (rather than getting calls from us).
  • What would work best for you? Would you prefer to Facetime, Skype, talk on the phone, text or email? What time of day is best? How about time each day, would that work for you? What is the best number or email address we can use to communicate with you each day?
  • What do you understand about the monitoring by [mechanism] that you are being asked to do during this time?  What challenges do you foresee with this plan?

Responding If Symptoms Develop

  • You will need to be aware of what is happening with your body, so that you can tell if you are developing any of the symptoms that we discussed.
  • If you develop any of the symptoms we discussed earlier, you should reach out to your primary care provider or the health department liaison/public health nurse so that they can assist you in getting care.
  • Where do you usually go when you are sick?
  • Who is your primary medical care provider?
  • Sometimes people with COVID-19 can have complications. if you have any emergency warning signs (including trouble breathing, persistent pain or pressure in the chest, new confusion, inability to wake or stay awake, or bluish lips or face). If you have any of these or any other symptoms that are severe or concerning to you, please call your medical provider or go to the emergency room (ER) right away. Don’t wait for your daily check-in. If you call 911 or go to the emergency room, wear a cloth face covering when an ambulance comes to get you or if you visit a medical provider. Also let them know that you received a call from the health department to notify you of possible exposure to COVID-19.
  • What is your plan if you develop symptoms? [Note: feedback and suggestions should be provided as relevant]
  • How would you get to the emergency room if needed?

Medical Provider and Other Support

  • What medical appointments/procedures do you have ahead of you? How comfortable do you feel communicating with them about being on quarantine?
  • Who do you feel comfortable reaching out to if you develop symptoms and you feel like you need support?

Other

  • This was a lot of information, what questions did this raise for you about COVID-19?

Aims: Check-in on agreements; Answer remaining questions; Set stage for follow-up

Check-in, Questions and Agreements

  • We have talked about a lot of topics today. I want to take a few minutes to check in on how you’re are feeling and discuss our agreements.
  • How are you feeling about all of this?
  • How can I (or my agency) be of additional assistance to you?
  • What questions do you have about what will happen next with the information that we have discussed?
  • So, our daily check-in starts tomorrow. What questions do you have about the time and the “method” that we discussed?
  • And if you start to feel symptoms of CVODI-19 your plan was to….?

Acknowledging the difficulty and keeping the door open for contact.

  • I just want to check in to be sure that you know how to reach me if you have other questions or concerns after we get off the phone. My name is spelled, , and my phone number is .
  • Either my colleague or I may reach out to you to check in to see if you are ok or whether you’ve connected with the other services we talked about today. They will also protect your privacy. We may have other questions that arise. Just wanted to confirm the best number to reach you is .
  • I can’t thank you enough for talking to me and helping us stop the spread of COVID-19 in [location]. I know this is a very difficult time for you and your family and we truly want everything to go well for you.
  • Before we hang up, I just want to check on what additional questions you may have for me?

Appendix A

This table is intended to guide the contact through an assessment of COVID-19 symptoms, onset and duration.  This information can help to identify contacts who will need to be referred for medical evaluation due to current symptom presentation, and also allow for discussion of which symptoms the contact should be “on the lookout” for during quarantine.

COVID-19 Symptoms  Presence of Symptoms Date of Onset Duration
COVID-19 SYMPTOM ASSESSMENT
Fever Check Box (Y/N/U/R) Date of onset Number of days
Cough Check Box (Y/N/U/R) Date of onset Number of days
Diarrhea/GI Check Box (Y/N/U/R) Date of onset Number of days
Headache Check Box (Y/N/U/R) Date of onset Number of days
Muscle ache Check Box (Y/N/U/R) Date of onset Number of days
Chills Check Box (Y/N/U/R) Date of onset Number of days
Sore throat Check Box (Y/N/U/R) Date of onset Number of days
Vomiting Check Box (Y/N/U/R) Date of onset Number of days
Abdominal pain Check Box (Y/N/U/R) Date of onset Number of days
Nasal congestion Check Box (Y/N/U/R) Date of onset Number of days
Loss of sense of smell Check Box (Y/N/U/R) Date of onset Number of days
Loss of sense of taste Check Box (Y/N/U/R) Date of onset Number of days
Malaise Check Box (Y/N/U/R) Date of onset Number of days
Fatigue Check Box (Y/N/U/R) Date of onset Number of days
Shortness of Breath or difficulty/trouble breathing* Check Box (Y/N/U/R) Date of onset Number of days
Persistent pain or pressure in the chest* Check Box (Y/N/U/R) Date of onset Number of days
New confusion* Check Box (Y/N/U/R) Date of onset Number of days
Inability to wake or stay awake* Check Box (Y/N/U/R) Date of onset Number of days
Bluish lips or face* Check Box (Y/N/U/R) Date of onset Number of days
Other symptom(s) Check Box (Y/N/U/R) Date of onset Number of days

*Emergency Warning Signs-Persons with these symptoms should be referred for emergency medical care.

KEY: Y=yes, N=no, U=Unknown, R=refused

Last Updated Aug. 27, 2020