MECKLENBURG COUNTY PUBLIC HEALTH | SAMPLE Positive COVID-19 Interview Questionnaire
Facility/Provider Ordering Test: __________________________________________________ Date Reported to MCPH: __________
Section 1: Patient Demographics
Ask about the following emergency warning signs for COVID-19. If someone is showing any of these signs, advise seeking
emergency medical care immediately:
trouble breathing | persistent pain or pressure in the chest | new confusion | inability to wake or stay awake | bluish lips or face
Name: ______________________________________________________________________________ DOB: __________________
Address: ____________________________________________________________________________________________________
____________________________________________________________________________________________________________
Residence Type: □ Private □ Long Term Care/Skilled Nursing Facility □ Shelter □ Homeless (Inform CD Supervisor/CD Manager)
□ Other: _____________________________________________________________________________________
Email Address: _____________________________________________________________________________________________
Cell Phone #: _________________________________ Other Phone #: ________________________________________
Sex: □ Male □ Female □ Unknown Gender (if different than Sex): □ Trans M-F □ Trans F-M □ Unknown □ N/A
Race: (check all that apply) □ Asian □ Black □ White □ American Indian/Alaskan Native □ Native Hawaiian □ Other □ Unknown
Hispanic-Latino? □ Yes □ No
Section 2: Patient Hospitalization & Risk Profile
Symptoms? □ Yes, date of onset: __________ □ No symptoms
Date of Test? __________
Chronic Medical Condition (check all that apply):
□ None □ Hypertension □ Heart Disease □ Lung Disease □ Diabetes □ Immunosuppression □ Other:_____________________
Hospitalized? □ Yes □ No
Any additional clinical notes: _______________________________________________________________________________
______________________________________________________________________________________________________
_
Section 3: Residential Public Health Risk Evaluation High Risk for COVID-19 Spread? □ Yes □ No
HRQ: Within the 2 days prior to symptom onset (or 2 days prior to date of test if asymptomatic) until now did you reside in
a group living facility? □ Yes □ No
o If yes, check facility type and enter facility name, address, start/end dates below:
□ Long Term Care Facility □ Correctional Facility □ Barracks □ Shelter □ Commune □ Boarding School □ Camp
□ Assisted Living Facility □ Dormitory/Sorority/Fraternity House □ Other: ___________________________________
Facility Name Address Start Date End Date
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MECKLENBURG COUNTY PUBLIC HEALTH | SAMPLE Positive COVID-19 Interview Questionnaire
Section 4: Occupational Public Health Risk Evaluation High Risk for COVID-19 Spread? □ Yes □ No
If yes, notify CD Supervisor/CD Manager.
Occupation: _________________________________________ Role: ___________________________________________________
HRQ: During the time period of 2 days prior to symptom onset (or 2 days prior to date of test if asymptomatic) until now,
have you worked on-site doing a job that involved close contacts (less than 6 feet from others for periods greater than 10 - 15
minutes) where there was the potential for exposing a large number of patrons or co-workers? □ Yes □ No
Last date worked: ____________________ Was work notified by case? □ Yes □ No
Notification: □ Not Needed □ Notified by CD RN/CI □ Contact attempted by CD RN/CI □ Unable to contact
□ Needs to be contacted (for contact by EN team when indicated; only if NOT a high-risk employer/occupation; see
Employer Notification Job Aid)
Employer’s Contact Information: __________________________________________________________________________
________________________________________________________________________________________________________
Section 5: Child Care/School/Adult Day Care Public Health Risk Evaluation High Risk for COVID-19 Spread? □ Yes □ No
Applicable if location currently open for on-site work/attendance. If yes, notify CD Supervisor/CD
Manager.
*Infectious period defined as within 2 days before symptom onset (or 2 days prior to date of test if asymptomatic) until now.
HRQ: Did case If yes, has
Child Care/School/Adult Day Care Risk Factor Location or Name of Facility work/attend while
(If yes to any, inform CD Supervisor/CD Manager.) facility been
infectious*? notified?
Is the case involved in childcare or
the parent/primary care giver of a □ Yes □ No □ Yes □ No □ Yes □ No
child in a childcare or camp setting?
Is the case a child or student who
□ Yes □ No □ Yes □ No □ Yes □ No
attended childcare or school
(includes colleges and universities)?
Is the case a school
worker/volunteer in a NC school □ Yes □ No □ Yes □ No □ Yes □ No
setting (includes colleges and
universities)?
Is case an attendee or worker at □ Yes □ No □ Yes □ No □ Yes □ No
an adult day care?
Section 6: Community Related Exposure Public Health Risk Evaluation High Risk for COVID-19 Spread? □ Yes □ No
HRQ: Did you attend any large event or group gathering within 2 days before symptom onset (or 2 days prior to date of
test if asymptomatic) until now? □ Yes □ No
If yes, please indicate location, event name, date(s) and other details:
_________________________________________________
________________________________________________________________________________________________________
__
HRQ: Did you visit a hospital, long-term care, or other healthcare facility (i.e. outpatient/urgent care/rehab) within 2 days
before symptom onset (or 2 days prior to date of test if asymptomatic) until now? □ Yes □ No
If yes, indicate facility name, address, date:
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MECKLENBURG COUNTY PUBLIC HEALTH | SAMPLE Positive COVID-19 Interview Questionnaire
______________________________________________________________________
HRQ: Did you fly during the period beginning 2 days before symptom onset (or 2 days before date of test if
asymptomatic) until now? □ Yes □ No
If yes, provide location, date, airline, flight # and seat #:
_____________________________________________________________________________________
If yes, did anyone you traveled with have the same or similar symptoms? □ Yes □ No □ Unknown
Section 7: Contacts Assessment
Household contacts?_______
Non-household contacts?____________
(List each individual on the contact list.)
Any contact with EMS, Fire or Police within 2 days before symptom onset (or 2 days prior to date of test if asymptomatic)
until now? □ Yes (Inform CD Supervisor/Designated CD Staff) □ No
If yes, indicate date/time/location:
___________________________________________________________________________
Section 8: Resource Evaluation
Are you able to self-isolate (avoid contact with others) at home? □ Yes □ No
If no, refer to isolation hotel. □ Patient accepted referral □ Patient declined referral
Are there any specific resources you may need during the self-isolation period such as:
□ Access to food □ Medications □ Rental assistance □ Other
If resource needs identified, are you interested in receiving a call from MCPH SW? □ Yes □ No
(Note: If individuals were tested through Atrium Health, they will receive SW support through Atrium for food, medications, and cleaning supplies)
Section 9: Patient Education / Isolation Orders
Review general COVID-19 care instructions.
Educate regarding individuals at high risk of serious complications if they get COVID-19.
Advise to notify close contacts if comfortable doing so. Contacts may call MCPH COVID-
19 Call Line: 980-314-9400.
Go over isolation orders and instructions and answer questions.
Section 10: MCPH Employees
Person Conducting Interview: ________________________________________________ Date/Time:
_________________________
Verbal Isolation Order Provided by:____________________________________________ Date/Time: _
Interpreter: _______________________________________________________________ Language: _______________________
Case Investigator Assigned to Case: _
Next Follow-Up Date Reminder: __________________________________
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MECKLENBURG COUNTY PUBLIC HEALTH | SAMPLE Positive COVID-19 Interview Questionnaire
Patient Name: _____________________________ DOB: ___________________ NCEDSS Case #:_______________________
Contacts Have contacts been added to CCTO?
□ Yes (Date added:__________________) □ No (Indicate Reason:_________________________________)
HOUSEHOLD:
Anyone living in the home? *For data entry staff; CCTO column: Y – entered as a contact; G; entered in group, N – not entered in CCTO.
Initial
Relationship to
DOB (if quarantine Date of Notes (include if
Case (e.g. parent,
Name Phone Number known) or guidance last contact tested CCTO
child, brother,
Age provided? exposure positive)
roommate, etc.)
(Y/N)
NON-HOUSEHOLD: Have you had any close contact (< 6 feet away for > 10-15 minutes) with individuals not work-related or
household-related within 48 hours before symptom onset (or date of test if asymptomatic) until now? □ Yes □ No
Priority should be given to identifying contacts who:
o Work in a high-risk occupation (e.g. healthcare, first responders, long-term care facility, congregate settings,
educational/childcare facility, critical infrastructure)
o Are at high risk for complications from COVID (e.g. age 65 and older, underlying chronic condition, immunosuppression)
o Live with and/or provide care for an individual at higher risk for complications from COVID-19
DOB (if County/State of Date of Last
Name Phone Number Notes (include if contact tested positive) CCTO
known) or Age Residence Exposure
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