Self Report Positive COVID-19 Test

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* 1. Did you test positive for COVID-19

Yes, Please continue to the rest of survey

No, self report is not needed

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* 2. Date of Test (MM/DD/YYYY)

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* 3. First Name

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* 4. Last Name

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* 5. Date of Birth (MM/DD/YYYY)

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* 6. Current Address

Address

City/Town

State

ZIP/Postal Code

Email Address

Phone Number

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* 7. Do you need a letter for school or work? If, Yes please provide email.

Yes-

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* 8. Result of Test

Positive

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* 9. What date your symptoms begin? ( MM/DD/YYYY)

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* 10. What symptoms did you or are having?
Mark all that apply

Fever

Nasal Congestion

Headache

Fatigue

Loss of Taste or Smell

Cough

Sore Throat

Muscle Aches

Shortness of Breath

Diarrhea

Nausea/Vomitting

Abdominal Pain

Altered Mental Status

Chest Pain/Pressure

Pale/Gray/Blue skin around lips or nail beds

Self Report Positive COVID-19 Test

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* 1. Did you test positive for COVID-19

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* 2. Date of Test (MM/DD/YYYY)

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* 3. First Name

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* 4. Last Name

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* 5. Date of Birth (MM/DD/YYYY)

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* 6. Current Address

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* 7. Do you need a letter for school or work? If, Yes please provide email.

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* 8. Result of Test

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* 9. What date your symptoms begin? ( MM/DD/YYYY)

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* 10. What symptoms did you or are having?Mark all that apply

* 10. What symptoms did you or are having?
Mark all that apply