Self-Reporting Survey for Positive COVID-19 Test Result

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* 1. Are you reporting positive results for yourself or someone else?

Myself

Someone else

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* 2. Provide the name of the individual tested.

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* 3. If you were not the individual tested, please provide your name.

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* 4. What is the date of birth of the individual tested?

Date / Time

Date

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* 5. Please provide the following information for the individual that tested positive.

Address

City

State

Zip Code

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* 6. On what date was the test done?

Date / Time

Date

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* 7. What is your phone number?

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* 8. Please submit a photo of the positive test result you received.

PDF, DOC, DOCX, PNG, JPG, JPEG file types only.