CDEs
Forms
[For employed persons] How has the COVID-19 outbreak affected you in the past two weeks
I believe I can protect myself from COVID-19
In the past two weeks has your family experienced the following as a result of covid-19?
Have recommendations for socially distancing caused stress for you?
Which of the following symptoms did you have?
Avoid going to a faith based gathering such as a church, synagogue, temple or mosque
Where did you seek care?
Avoid going out to a restaurant, bar or club
Avoid visiting with older (60 years +) family members
For this illness did you seek advice from a healthcare professional?
How long after your symptoms started did you seek care?
For this illness, were you tested for influenza?
Avoid visiting with other older (60 years +) adults such as friends or neighbors
Presence of underlying conditions
Is there community spread of COVID where you are living?
Health insurance type
Symptom onset date and time
Age
BP sys
BP dias
1
2
3