IRVINE INFORMATION INITIATIVE

Part of the Irvine Innovation Initiative

Information is key for our city to be able to support the entire community.

We are asking every resident in Irvine to provide as much information as possible in order for us to serve the entire community, provide services where needed and set an example for a national model to be able to respond the most effectively to this pandemic.

Please submit the information requested below so that our health officials can have the information we need to coordinate all appropriate support.

The information provided will be used only for this initiative and will not be shared with anyone else.

Name

Please enter your full name.

First Name

Last Name

Primary Residence

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Please enter your email address for follow up questions if necessary.

Household Primary Phone

Please provide a primary household phone for follow questions if necessary.

(###)

###

####

Mobile Phone

Please provide a mobile phone for follow questions if necessary.

(###)

###

####

How many people in Household

This includes everyone including yourself who lives in your primary residence.

Ages and Genders in Household

Example: Male - 45 Female - 38 Maie - 18 Female - 10

Have you been tested for COVID-19?

Choose one

If you've been tested, did you have COVID-19?

Please enter your test results either for active infection or antibody test.

If you did not get tested, do you think you might have had COVID-19?

If you think you might have had the virus in the past 6 months, please select Yes.

When is the MOST RECENT time you felt ill in the last 6 months?

Please choose the best option for the most recent time you've felt sick in the past 6 months.

Are you going to work?

Please select best answer.

On average how many people do you interact with a day?

Outside of going to the market and other shopping outings, how many people do you interact with regularly? This includes you household members, neighbors you interact with, people in your office or work?

Do you wear a mask?

Select the best answer.

Have you been in a large crowd of over 10 since March 15?

This does not apply to going to stores or other shopping experiences.

How many people have been sick in your household since February 1st?

Please enter the number of people in your household that have been sick. Please enter 0 if none.

Names in household who have been sick since February 1

Please enter first and last names of those that have been ill since February 1 in your household.

Names and numbers of those in Irvine you know have been ill since February 1