Self Reporting of Positive COVID-19 Home Test

If you or a family member have obtained an at-home COVID-19 self-test kit and your results were positive, please provide answers to the following questions. These questions are used as a surveillance tool to identify the number of individuals who have tested positive through at-home tests. This will provide the health department a more detailed picture into our communities positivity rate. Thank you!

Question Title

1. Please provide the following information for the person who tested positive for COVID-19 (Required.)

Name

DOB (mm/dd/yyyy)

Address

City/Town

State/Province

ZIP/Postal Code

Phone Number

Question Title

2. What date did you do your home test? (Required.)

Date / Time

Date

Question Title

3. Type of Test Used at Home: (Required.)

Please specify the type of test used if it is not listed above:

Self Reporting of Positive COVID-19 Home Test

Question Title

* 1. Please provide the following information for the person who tested positive for COVID-19 (Required.)

Question Title

* 2. What date did you do your home test? (Required.)

Question Title

* 3. Type of Test Used at Home: (Required.)

Question Title

* 4. What was the result of your test? (Required.)

1. Please provide the following information for the person who tested positive for COVID-19 (Required.)

2. What date did you do your home test? (Required.)

3. Type of Test Used at Home: (Required.)

4. What was the result of your test? (Required.)