The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

TcznYALYZVsI6AF2FDICofkxCGN5bB33Mhi2dPQ6

COVID-19 Report Form

This form is for COVID-19 results only. Enter as much information as you have available.

The "patient" is the person with a positive test being reported.

During times with high case numbers in the community, persons reported through this form may not receive an interview.

Required fields are highlighted in red.

Whatcom County Health Department
Report Line: 360-778-6150
Confidential Fax number: 360-778-6103
Email: health-dert@co.whatcom.wa.us

Facility (if applicable)	Reporter Name	Contact Number	Date Completed

Last Name	First Name	Birth Date

Primary Language	Phone	Sex assigned at birth

Race	Ethnicity

Address	City	Zip

Is the patient employed or do they volunteer in a high-risk facility?

Yes No Unknown

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Employer/Volunteer Facility Name

Does patient live in a high-risk setting?

Acute or Long-term care setting

Correctional Facility

Shelter or transitional housing

Communal housing such as a dormitory

Other

Please describe

Symptomatic?

* must provide value

Yes No

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First symptom onset date

M-D-Y

Symptoms
(Select all that apply)

Fever

Cough

Body aches

Shortness of breath

Chills

Sore throat

Sinus congestion

Pneumonia

Diarrhea

Nausea

Abdominal Pain

Headache

Loss of taste

Loss of smell

Other

Was the patient hospitalized due to this illness?

Yes No Unknown

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Hospital Name	Admission Date	Discharge Date

Did the patient have a known exposure 1-14 days before symptom onset (or likely past exposure if
asymptomatic)?

Yes No Unknown

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Name of source exposure	Date of first exposure	Date of last exposure

Details

Travel 1-14 days before symptoms onset (or relevant past travel history if asymptomatic)?

Yes No Unknown

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Travel destination	Arrival date	Return date

Details

Please attach a copy of lab results if available >

Name of test	Test Type	Result	Collection date

Ex: "BinaxNow" Leave blank if unknown.

Expand

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To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.

COVID-19 Report Form

Name of test

Test Type

Result

Collection date

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