OHA 3460A Oregon Health Authority COVID-19 Case Data Form



Oregon Health Authority COVID-19 Case Data Form(For use in surge situations only)Case first name: FORMTEXT ?????Case last name: FORMTEXT ?????ELR test date: FORMTEXT MM/ FORMTEXT DD/ FORMTEXT YYYYOrpheus case ID #: FORMTEXT ?????Interviewer name: FORMTEXT ?????1st call attempt: FORMTEXT MM/ FORMTEXT DD/ FORMTEXT YYYYCurrent Sex: FORMTEXT ?????OPERA DOB: FORMTEXT MM/ FORMTEXT DD/ FORMTEXT YYYYIF INCORRECT: PROVIDED DOB FORMTEXT MM/ FORMTEXT DD/ FORMTEXT YYYY ? STOP: RE-CHECK DOB BEFORE COMPLETING INTERVIEWIn the event of a deceased individualIs the person deceased? FORMCHECKBOX Yes FORMCHECKBOX No If yes, date of death: FORMTEXT MM/ FORMTEXT DD/ FORMTEXT YYYY (Continue interview if possible)You will likely find out early in the interview if someone is deceased. Please express your condolences:I’m very sorry about your loss. We were not aware that [Name] had passed on. This must be a difficult time for you and the family and friends of [Name]. We want to give you the time you need to grieve. Who would be the most suitable person to speak with regarding [Name]’s illness, and when would be a better time to follow up? FORMTEXT ????? FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT MM/ FORMTEXT DD/ FORMTEXT YYYYName Contact number Follow-up date/timeDemographicsREAL-D: Language/communicationWhat language or languages do you use at home? FORMTEXT ?????If English only, skip to Disability section.If other language indicated above:In what language do you want us to communicate with you on the phone? FORMTEXT ?????In what language do you want us to write to you? FORMTEXT ????? If English only for both, skip to Disability section.I speak FORMTEXT ?????. Do you need an interpreter for us to communicate with you? FORMCHECKBOX Yes FORMCHECKBOX No If yes, select an option below:Spoken language interpreterAmerican Sign LanguageDeaf Interpreter for Deaf Blind and Deaf with additional barriersContact sign language or PSE interpreterOther FORMTEXT ?????If language spoken at home is not sign language: How well do you speak English? (Read response options)Not at all FORMCHECKBOX Not well FORMCHECKBOX Well FORMCHECKBOX Very well FORMCHECKBOX COPY FROM OPERA RECORDCOMPLETE THIS COLUMN ONLY IF OPERA NEEDS UPDATINGPhone: FORMTEXT ???- FORMTEXT ???- FORMTEXT ????Address: FORMTEXT ?????City/ZIP: FORMTEXT ?????, OR FORMTEXT ?????Receive Mail at this Address? FORMCHECKBOX YesSend follow up letter: FORMCHECKBOX Email FORMCHECKBOX Postal MailPhone: FORMTEXT ???- FORMTEXT ???- FORMTEXT ????Home address: FORMTEXT ?????City/ZIP: FORMTEXT ?????, OR FORMTEXT ?????2888124-662748**If high-risk living situation, complete section below**00**If high-risk living situation, complete section below**Mailing address, if different FORMTEXT ?????City/ZIP FORMTEXT ?????, OR FORMTEXT ?????If Email: FORMTEXT ?????What type of residence is this? FORMCHECKBOX Single family FORMCHECKBOX Multifamily FORMCHECKBOX Group home (list continues below)(cont’d) High risk living situations **REPORT TO TEAM LEAD/COUNTY IF NOT PREVIOUSLY KNOWN** FORMCHECKBOX Unstably housed or houseless FORMCHECKBOX LTCF or skilled nursing facility FORMCHECKBOX Correctional facility FORMCHECKBOX Dormitory or other housing with shared space FORMCHECKBOX Employer-provided congregate housing FORMCHECKBOX Other – describe: FORMTEXT ?????If any boxes are checked, fill in if available:FACILITY name: FORMTEXT ?????POINT OF CONTACT name: FORMTEXT ?????POINT OF CONTACT phone: FORMTEXT ???- FORMTEXT ???- FORMTEXT ????Other notes: FORMTEXT ?????REAL-D: Disability questions: “I am now going to ask you some questions about disabilities. Your answers will help us find health and service differences among people with and without functional difficulties. Your answers are confidential.”Are you deaf or do you have serious difficulty hearing? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes: At what age did this condition begin? FORMTEXT ?????Are you blind or do you have serious difficulty seeing, even when wearing glasses? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes: At what age did this condition begin? FORMTEXT ?????For ages 5+:Do you have serious difficulty walking or climbing stairs? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Don’t know FORMCHECKBOX RefusedIf yes: At what age did this condition begin? FORMTEXT ?????Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Don’t know FORMCHECKBOX RefusedIf yes: At what age did this condition begin? FORMTEXT ?????Do you have difficulty dressing or bathing? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Don’t know FORMCHECKBOX RefusedIf yes: At what age did this condition begin? FORMTEXT ?????Do you have serious difficulty learning how to do things most people your age can learn? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Don’t know FORMCHECKBOX RefusedIf yes: At what age did this condition begin? FORMTEXT ?????Using your usual or customary language, do you have serious difficulty communicating, for example, difficulty understanding or being understood by others? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Don’t know FORMCHECKBOX Refused If yes: At what age did this condition begin? FORMTEXT ?????For ages 15+: Because of a physical, mental, or emotional condition, do you have serious difficulty doing errands alone, such as visiting a doctor’s office or shopping? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Don’t know FORMCHECKBOX RefusedIf yes: At what age did this condition begin? FORMTEXT ?????Do you have serious difficulty with the following: mood, intense feelings, controlling your behavior, or experiencing delusions or hallucinations? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Don’t know FORMCHECKBOX Refused If yes: At what age did this condition begin? FORMTEXT ?????Wraparound services: “Public health is not just about staying free of symptoms, it is about having access to the resources and support needed to remain healthy. This is even more important when we need to stay home to prevent the spread of COVID-19. We’ll talk more about staying home later in this phone call, but first I want to know:”Do you/your family have access to food you need to stay home? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnsureDo you need help paying your housing or utility bills? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnsureDo you have family, friends, or neighbors outside your home that you can ask for help with running errands? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnsureIf support is needed: Do you consent to local public health sharing your contact information to the local community-based organization that can provide you with these services? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnsureIt can be hard to predict what needs will arise if you are being asked to stay home for a while. The number for FORMTEXT {Enter county name} County will also be included in the follow up information you receive. Please reach out later if needs arise.We will send you follow up information from this call. Would you like to receive it by postal mail or email? FORMCHECKBOX Postal mail FORMCHECKBOX Email What is your email address? FORMTEXT ?????Clinical tabSymptom onsetHave you been feeling sick? FORMCHECKBOX YesàWhat was the first date you can remember feeling ill? Or best guess. FORMTEXT MM/ FORMTEXT DD/ FORMTEXT YYYY FORMCHECKBOX Indeterminate FORMCHECKBOX NoàUse ELR specimen collection date (first page) as onset date FORMCHECKBOX Refused FORMCHECKBOX UnknownHospitalizationHave you had to stay overnight at the hospital since your Coronavirus diagnosis? FORMCHECKBOX Yes FORMCHECKBOX NoIf hospitalized:Do you know the name of the hospital where you were admitted? FORMTEXT ?????Do you remember what dates you were at the hospital?Admit FORMTEXT MM/ FORMTEXT DD/ FORMTEXT YYYYDischarge FORMTEXT MM/ FORMTEXT DD/ FORMTEXT YYYYIf hospitalized:Were you transported by EMS to the hospital? FORMCHECKBOX YesDate: FORMTEXT MM/ FORMTEXT DD/ FORMTEXT YYYYTime: FORMTEXT ?????Ambulance company: FORMTEXT ????? FORMCHECKBOX No FORMCHECKBOX UnknownWork/school/volunteering outside the houseIn the two weeks before you started feeling sick (or: tested positive) to today, did you work, attend school, (if young child: daycare) or volunteer, such as helping someone else outside your home? FORMCHECKBOX Yes-Work FORMCHECKBOX Yes-Student FORMCHECKBOX Yes-Other: FORMTEXT ????? FORMCHECKBOX None FORMCHECKBOX Remote only FORMCHECKBOX On leaveSKIP WORK – GO TO RISK/FOLLOW UP SECTIONIf yes: What is the name and location?Work/school/daycare/volunteer site name: FORMTEXT ?????Address: FORMTEXT ?????City: FORMTEXT ????? State: FORMTEXT ????? ZIP code: FORMTEXT ?????What do you do/what is your role there? (Occupation) FORMTEXT ?????If location is different from home city: Verify same or different countyIf different: Case works in FORMTEXT ????? CountyàAssign Opera note to County with worksite information.Last day worked/attended school or daycare/volunteeredWhat is the last day that you were at work/school/volunteered? Date: FORMTEXT MM/ FORMTEXT DD/ FORMTEXT YYYYDo you need a letter for work? FORMCHECKBOX Yes FORMCHECKBOX No(complete next section)Workplace contact (enter as Opera Note)“We will follow-up with your employer to let them know of a worksite exposure to Coronavirus. You can also follow-up with them directly if you would like to share this information with them. We will notify your employer that an employee has tested positive for COVID-19, and we will do our best to maintain your confidentiality in this notification. Our goal is to allow your employer to take precautions to protect other staff and those you work with. Will you share your HR’s or supervisor’s information with me?” FORMTEXT ????? FORMTEXT ?????HR/supervisor’s nameHR/supervisor’s phone and/or emailHigh risk employment/school/volunteer situationsWorked in/attended School or daycare within 14 days of onset?**REPORT WHEN DONE** FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unsure FORMCHECKBOX RefusedIf yes: FORMCHECKBOX School – K-12 (including Pre-K and preschools attached to K-12 school) FORMCHECKBOX Daycare center/preschool (excluding Pre-K and preschools attached to K-12 school) FORMCHECKBOX Sports practice or game FORMCHECKBOX Extracurriculars FORMCHECKBOX Higher education If yes: Does the case reside in on-campus housing (including Greek life housing)? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unsure FORMCHECKBOX Refused If yes: Was the student or staff fully remote? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unsure FORMCHECKBOX RefusedHigh risk employment/school/volunteer situationsWorked in Healthcare, EMS or other Care facility within 14 days of onset?**REPORT WHEN DONE** FORMCHECKBOX Yes FORMCHECKBOX No If yes: Do you provide direct patient care? FORMCHECKBOX Yes FORMCHECKBOX NoType of setting: FORMCHECKBOX LTCF/skilled nursing FORMCHECKBOX Dialysis FORMCHECKBOX Hospital FORMCHECKBOX Ambulatory surgery FORMCHECKBOX EMS FORMCHECKBOX Other: FORMTEXT ?????Worked/volunteered in other High risk setting within 14 days of onset? **REPORT WHEN DONE** FORMCHECKBOX Yes FORMCHECKBOX NoCongregate Settings: FORMCHECKBOX Dorm or other high-density residence FORMCHECKBOX Works closely with other people FORMCHECKBOX Correctional facility FORMCHECKBOX Interacts with the public FORMCHECKBOX Confined workspace FORMCHECKBOX Farm/food processing FORMCHECKBOX Other – please describe: FORMTEXT ?????Vulnerable populations: FORMCHECKBOX Elderly (60 years or older) FORMCHECKBOX Immunocompromised FORMCHECKBOX Correctional facility FORMCHECKBOX Pregnant FORMCHECKBOX Houseless or unstably housed people FORMCHECKBOX Farm/food processing worker (REFER to 888-274-7292 or for Worker Relief Fund)Do you receive your pay from the worksite, or a different organization such as placement agency? FORMCHECKBOX Yes FORMCHECKBOX NoDo they also provide housing and/or transportation? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX Other – please describe vulnerable population: Risk and follow up tabsExposure in public settingsFrom 2 days before you started feeling sick [or: tested positive] until now, have you been anywhere where you may have been in close contact with others? Close contact means within 6 ft, for >15 min. Note: If the case indicates exposure in a healthcare setting during their infectious period, they should call and alert the facility of the potential exposure.SettingName of placeDatesContact info/phoneAddress/city FORMCHECKBOX Day care FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX School/college FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Work FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Correctional facility or jail FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Other FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Unknown FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Contacts and epi links tabsHousehold contactsNext, I’d like to know about the people who live at your address, and if anyone has been sick. Later I will share important information on how everyone around you can stay healthy.First and last name[First name required]SexRelationshipDOB or ageCOVID-19 tested?Sick?If yes, SxPhone number(if different) [Required] FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMCHECKBOX Non-binary FORMCHECKBOX Unknown FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX FORMTEXT ????? FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMCHECKBOX Non-binary FORMCHECKBOX Unknown FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX FORMTEXT ????? FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMCHECKBOX Non-binary FORMCHECKBOX Unknown FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX FORMTEXT ????? FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMCHECKBOX Non-binary FORMCHECKBOX Unknown FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX FORMTEXT ????? FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMCHECKBOX Non-binary FORMCHECKBOX Unknown FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX FORMTEXT ????? FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMCHECKBOX Non-binary FORMCHECKBOX Unknown FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX FORMTEXT ????? FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMCHECKBOX Non-binary FORMCHECKBOX Unknown FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX FORMTEXT ????? FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMCHECKBOX Non-binary FORMCHECKBOX Unknown FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX FORMTEXT ????? FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMCHECKBOX Non-binary FORMCHECKBOX Unknown FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX FORMTEXT ????? FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMCHECKBOX Non-binary FORMCHECKBOX Unknown FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX FORMTEXT ????? FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMCHECKBOX Non-binary FORMCHECKBOX Unknown FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX FORMTEXT ????? FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMCHECKBOX Non-binary FORMCHECKBOX Unknown FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX FORMTEXT ????? FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMCHECKBOX Non-binary FORMCHECKBOX Unknown FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX FORMTEXT ????? FORMTEXT ???- FORMTEXT ???- FORMTEXT ????High-risk work contacts Think about the time from two days before you started feeling sick [or: tested positive], up until [today, or end of isolation period, whichever comes first]. Are there any people at your work you’ve had close contact with, including transportation to/from work? Close contact means within 6 ft for more than 15 mins within 24 hours.First and last name[First name required]DOB/ageif knownSexPhone number[Required]Address, if knownLast exposure date [Required] FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMCHECKBOX Non-binary FORMCHECKBOX Unknown FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT ????? FORMTEXT MM/ FORMTEXT DD/ FORMTEXT YYYY FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMCHECKBOX Non-binary FORMCHECKBOX Unknown FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT ????? FORMTEXT MM/ FORMTEXT DD/ FORMTEXT YYYY FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMCHECKBOX Non-binary FORMCHECKBOX Unknown FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT ????? FORMTEXT MM/ FORMTEXT DD/ FORMTEXT YYYY FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMCHECKBOX Non-binary FORMCHECKBOX Unknown FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT ????? FORMTEXT MM/ FORMTEXT DD/ FORMTEXT YYYY FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMCHECKBOX Non-binary FORMCHECKBOX Unknown FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT ????? FORMTEXT MM/ FORMTEXT DD/ FORMTEXT YYYY FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMCHECKBOX Non-binary FORMCHECKBOX Unknown FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT ????? FORMTEXT MM/ FORMTEXT DD/ FORMTEXT YYYY FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMCHECKBOX Non-binary FORMCHECKBOX Unknown FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT ????? FORMTEXT MM/ FORMTEXT DD/ FORMTEXT YYYY FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMCHECKBOX Non-binary FORMCHECKBOX Unknown FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT ????? FORMTEXT MM/ FORMTEXT DD/ FORMTEXT YYYY FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMCHECKBOX Non-binary FORMCHECKBOX Unknown FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT ????? FORMTEXT MM/ FORMTEXT DD/ FORMTEXT YYYY FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMCHECKBOX Non-binary FORMCHECKBOX Unknown FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT ????? FORMTEXT MM/ FORMTEXT DD/ FORMTEXT YYYY FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMCHECKBOX Non-binary FORMCHECKBOX Unknown FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT ????? FORMTEXT MM/ FORMTEXT DD/ FORMTEXT YYYY FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMCHECKBOX Non-binary FORMCHECKBOX Unknown FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT ????? FORMTEXT MM/ FORMTEXT DD/ FORMTEXT YYYYHigh-risk social contactsStill thinking about the time from two days before you started feeling sick [or: positive test], up until [today, or end of isolation period, whichever comes first], Are there any friends or family outside your home, or other social groups where you might have had close contact? Again, close contact means within 6 ft for more than 15 mins.First and last name[First name required]DOB/ageif knownSexPhone number[Required]Address, if knownLast exposure date [Required] FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMCHECKBOX Non-binary FORMCHECKBOX Unknown FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT ????? FORMTEXT MM/ FORMTEXT DD/ FORMTEXT YYYY FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMCHECKBOX Non-binary FORMCHECKBOX Unknown FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT ????? FORMTEXT MM/ FORMTEXT DD/ FORMTEXT YYYY FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMCHECKBOX Non-binary FORMCHECKBOX Unknown FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT ????? FORMTEXT MM/ FORMTEXT DD/ FORMTEXT YYYY FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMCHECKBOX Non-binary FORMCHECKBOX Unknown FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT ????? FORMTEXT MM/ FORMTEXT DD/ FORMTEXT YYYY FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMCHECKBOX Non-binary FORMCHECKBOX Unknown FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT ????? FORMTEXT MM/ FORMTEXT DD/ FORMTEXT YYYY FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMCHECKBOX Non-binary FORMCHECKBOX Unknown FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT ????? FORMTEXT MM/ FORMTEXT DD/ FORMTEXT YYYY FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMCHECKBOX Non-binary FORMCHECKBOX Unknown FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT ????? FORMTEXT MM/ FORMTEXT DD/ FORMTEXT YYYY FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMCHECKBOX Non-binary FORMCHECKBOX Unknown FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT ????? FORMTEXT MM/ FORMTEXT DD/ FORMTEXT YYYY FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMCHECKBOX Non-binary FORMCHECKBOX Unknown FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT ????? FORMTEXT MM/ FORMTEXT DD/ FORMTEXT YYYY FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMCHECKBOX Non-binary FORMCHECKBOX Unknown FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT ????? FORMTEXT MM/ FORMTEXT DD/ FORMTEXT YYYY FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMCHECKBOX Non-binary FORMCHECKBOX Unknown FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT ????? FORMTEXT MM/ FORMTEXT DD/ FORMTEXT YYYY FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMCHECKBOX Non-binary FORMCHECKBOX Unknown FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT ????? FORMTEXT MM/ FORMTEXT DD/ FORMTEXT YYYY FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMCHECKBOX Non-binary FORMCHECKBOX Unknown FORMTEXT ???- FORMTEXT ???- FORMTEXT ???? FORMTEXT ????? FORMTEXT MM/ FORMTEXT DD/ FORMTEXT YYYYREAL D: Race ethnicityWe ask everyone who tests for coronavirus about racial and ethnic background in order to make sure all Oregonians receive the best possible public health service, to prevent others in your community from becoming ill, and to understand how the virus is impacting communities. How do you identify your race, ethnicity, tribal affiliation, country of origin, or ancestry?You can use any words you like. FORMTEXT ?????Here are some more specific categories. Which of these describe your racial or ethnic identity? You can choose more than one answer. [Check all that apply.]American Indian or Alaska Native FORMCHECKBOX American Indian FORMCHECKBOX Alaska Native FORMCHECKBOX Canadian Inuit, Metis, First Nation FORMCHECKBOX Indigenous Mexican, Central/South AmericanHispanic or Latino/a/x FORMCHECKBOX Hispanic or Latinx Central American FORMCHECKBOX Hispanic or Latinx Mexican FORMCHECKBOX Hispanic or Latinx South American FORMCHECKBOX Other Hispanic or LatinxNative Hawaiian or Pacific Islander FORMCHECKBOX Guamanian FORMCHECKBOX Chamorro FORMCHECKBOX Micronesian FORMCHECKBOX Native Hawaiian FORMCHECKBOX Samoan FORMCHECKBOX Tongan FORMCHECKBOX Other Pacific IslanderAsian FORMCHECKBOX Asian Indian FORMCHECKBOX Chinese FORMCHECKBOX Filipino/a FORMCHECKBOX Hmong FORMCHECKBOX Japanese FORMCHECKBOX Korean FORMCHECKBOX Laotian FORMCHECKBOX South Asian FORMCHECKBOX Vietnamese FORMCHECKBOX Other AsianWhite FORMCHECKBOX Eastern European FORMCHECKBOX Slavic FORMCHECKBOX Western European FORMCHECKBOX Other WhiteBlack or African American FORMCHECKBOX African American FORMCHECKBOX African (Black) FORMCHECKBOX Caribbean (Black) FORMCHECKBOX Other BlackMiddle Eastern/Northern African FORMCHECKBOX Northern African FORMCHECKBOX Middle EasternOther categories FORMCHECKBOX Unknown FORMCHECKBOX Declined FORMCHECKBOX Other: FORMTEXT ?????If multiple races mentioned: Is there one race/ethnicity you think of as your primary racial or ethnic identity? FORMCHECKBOX Yes FORMCHECKBOX No, I identify as Biracial/ Multiracial FORMCHECKBOX I don’t have just one primary identity FORMCHECKBOX Don’t want to answer (Refused) FORMCHECKBOX Don’t know? STOP ? END OF INTERVIEW[DON’T READ] Case educationDid the case receive the post-interview education (script) on how to reduce the risk of disease transmission? FORMCHECKBOX Yes (if post-interview script completed) FORMCHECKBOX No[DON’T READ] EpiLink: Case is believed to have acquired COVID from: FORMCHECKBOX Household (HH) FORMCHECKBOX Non-HH close contact (CC) FORMCHECKBOX Workplace, mass gathering, or other OB FORMCHECKBOX None known (SP)Notes FORMTEXT ?????You can get this document in other languages, large print, braille, or a format you prefer. Contact the Coronavirus Response and Recovery Unit (CRRU) at 503-979-3377 or email CRRU@dhsoha.state.or.us. We accept all relay calls or you can dial 711. ................
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