Communicable Disease Control Order Form - Live Well Wichita County

Date*

To End user:

Based on your positive test result of a communicable disease: novel coronavirus disease, known as COVID-19, you are being issued this control order. Your local health department is the Wichita Falls-Wichita County Public Health District. You can contact them at 940-761-7800 twenty-four hours a day, seven days a week. Under the authority of Texas Health and Safety Code §81.083 you are hereby ordered to implement the following control measures, effective immediately, that are reasonable and necessary to prevent the introduction, transmission, and spread of this disease in this state:

Enter Case Number*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

(Please confirm your understanding by initialing each paragraph.)

Remain at your current address, or cooperate with and be transported to and then remain at a Hospital or another appropriate facility (Facility) as determined by the Wichita Falls-Wichita County Public Health District. You will not be permitted to leave the Residence, Hospital, or Facility for any reason other than to seek medical evaluation or care, and must first contact your local health department to obtain approval before leaving the premises.*

I agree.

If you need an ambulance, you must tell the ambulance staff about this control order and your COVID-19 exposure when requesting assistance. You must also contact Wichita Falls-Wichita County Public Health District at 940-761-7800, to inform them of your need for an ambulance.*

I agree.

You will not be permitted to have any visitors at the Residence, Hospital, or Facility without the prior approval of the Wichita Falls-Wichita County Public Health District.*

I agree.

You will be monitored by public health personnel at least once a day. A public health worker will monitor your temperature and check for symptoms, such as fever (measured ≥100◦F or subjective), chills, cough, shortness of breath/difficulty breathing, sore throat, runny nose, muscle aches, fatigue, headache, abdominal pain/discomfort, nausea, diarrhea, vomiting. Monitoring timeframe and clearance is evaluated on a case by case basis.*

I agree.

You must immediately notify the local health department if you develop fever or other symptoms.*

I agree.

You must make yourself available to representatives of the Hospital, Facility, the Department of State Health Services, U. S. Centers for Disease Control and Prevention, and/or the Wichita Falls-Wichita County Public Health District for diagnostic testing, providing them with blood and other samples or any other measures, treatment, monitoring, or tests required by any of the entities above, to prevent the spread of a communicable disease, on request by any of the entities listed above.*

I agree.

If you do not comply with these control measures you may be subject to criminal prosecution under Texas Health and Safety Code §81.087, or civil court proceedings under Texas Health and Safety Code Chapter 81, Subchapter G, entitled “Court Orders for Management of Persons with Communicable Diseases.”*

I agree.

This Order will remain in effect until you are notified in writing that (1) the incubation period has passed and you are no longer suspected of having the above-stated communicable disease; or (2) you are otherwise notified by the Department of State Health Services. See Texas Health & Safety Code §81.083(d).*

I agree.

ISSUED PURSUANT TO MY AUTHORITY AS THE ACTING LOCAL HEALTH AUTHORITY FOR THE WICHITA FALLS-WICHITA COUNTY PUBLIC HEALTH DISTRICT DATED ON THE DATE AS INDICATED ABOVE.

Arthur J. Szczerba, M.D., C.M.D., F.A.A.F.P.

Medical Director, Wichita Falls-Wichita County Public Health District

Local Health Authority, Wichita County

Certificate of Service

I, _________________, hereby certify that the foregoing Control Order was served by the following:

Lou's Signature HERE

Acknowledgement of Receipt

I, ___________________, hereby acknowledge receipt of this Control Order on __________________.

E-Signature

I agree hereby acknowledge receipt of this Control Order on the date indicated above.

Name*

First Last