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COVID-19-Questionaire

Contact Tracing Questionnaire

The information from this survey will be used to understand the spread and impacts of the infection. Your participation in this project is voluntary. If you prefer not to answer a question, you may skip that question. If you prefer not to complete the survey, you can disregard the survey. This research is being conducted by G-Health Enterprises and Affiliates.  All personal information will be kept strictly confidential. If you have any questions regarding this research project, please contact: Chelsea.adamski@gbuahn.org or call 716-604-0504
Name(*)
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Age(*)
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Phone(*)
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Are you currently experiencing or have you previously experienced any of the following symptoms? Check all that apply:(*)

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When did you first start to experience these symptoms:(*)
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Have you been in close contact with someone who has been exposed?(*)
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How do you travel locally in Western New York? Check all that apply:(*)
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If you chose “other”, please specify:(*)
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Were you hospitalized?(*)
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If yes, were you on a ventilator?(*)
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Do you have any chronic medical conditions? Check all that apply:(*)
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If you chose “other”, please specify:(*)
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How many people live in the home including yourself?(*)
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Is anyone in the home experiencing any of the symptoms listed in Question 1?(*)
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If anyone in the home has symptoms, can we contact them for a nurse evaluation and possible testing?(*)
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What is the best way to contact these individuals for a nurse evaluation? Please provide any phone numbers or e-mails where we can reach out(*)
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Human Verify
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