COVID-19 Positive Test Self Report
Please complete this form if you have tested positive with an at home COVID test kit. This form is voluntary and not required. Answer the questions to the best of your ability.
Name
First Name
Last Name
Birthdate
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Biological Sex
Male
Female
Are you currently pregnant?
Yes
No
Date Test Performed
-
Month
-
Day
Year
Date
What is the name of the test you took?
Do or did you have symptoms
Yes
No
Date symptoms started
-
Month
-
Day
Year
Date
Select ALL symptoms you experienced
Fever greater than 100.4
Chills
Muscle Ache(s)
Runny nose
Sore Throat
Change to taste OR smell
Headache
Cough
Fatigue
Wheezing
Shortness of breath
Difficulty breathing
Chest Pain
Nausea or vomiting
Abdominal pain
Diarrhea
Are you vaccinated against COVID-19
Yes
No
Which vaccine did you receive
Pfizer
Moderna
J&J
How many doses of the vaccine have you received?
One
Two
Three
In the last 10 days prior to onset of symptoms or positive test
Attend an event/meeting with 10 or more people
Travel by mass transit (train/bus/airplane)
Visit or work in a congregate setting such as: school, hospital/clinic, manufacturing plant, long term care facility
Was a close contact to a known COVID-19 case
Submit
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