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COVID-19 Symptom Reporting Form

  1. Clear Creek County COVID-19 Symptom Self Reporting Form

    Please fill out a single form for EACH person showing symptoms. All personal information will remain confidential and will be HIPAA-protected. With community-level transmission of COVID-19 confirmed across Colorado, testing is being reserved for the most critical cases. It is important, however, that we continue to be able to track the spread of COVID-19 to align response resources in Clear Creek County and evaluate the strategies in place to decrease the spread of illness in our community. This information will help evaluate areas being impacted and types of symptoms being experienced. Most people who get COVID-19 experience mild symptoms and do not require direct medical care; however, information regarding any symptoms help our public health team understand the virus. If you have symptoms, but are otherwise feeling ok, please self-isolate for 14 days and fill out this form. If you are symptomatic and worsening, please call (303) 670-7545 or your primary care physician. If it is an emergency, please call 911.

  2. GENDER*

  3. HAVE YOU BEEN IN CLOSE CONTACT WITH SOMEONE THAT HAS BEEN CONFIRMED COVID-19 POSITIVE?*

  4. ARE YOU IMMUNOCOMPROMISED?*

    Immunocompromised means you have a weakened immune system. this may be caused by certain diseases or conditions, such as AIDS, cancer, diabetes, malnutrition, and certain genetic disorders. It may also be caused by certain medicines or treatments

  5. DO YOU HAVE ANY PRE-EXISTING CONDITIONS? SUCH AS DIABETES, HEART DISEASE OR LUNG DISEASE*

  6. PLEASE SELECT THE SYMPTOMS THAT YOU ARE EXPERIENCING:*

    If any of your symptoms are severe and you need immediate medical assistance, please call 911.

  7. If you have additional pertinent information regarding your symptoms or potential exposure to COVID-19 that you would like to provide, please provide the information above.

  8. DISCLAIMER

    By submitting this form you are consenting to be contacted by the Clear Creek County for follow-up regarding your submittal. Submitting this form does not guarantee you will receive a test COVID-19. Testing is extremely limited and is based on a tiered evaluation.

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  10. This field is not part of the form submission.