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Self-Reporting COVID-19 Test Results

Thank you for self-reporting a positive COVID-19 test result to the Taney County Health Department. Please note only a positive PCR test is confirmatory for COVID-19 per the CDC guidelines. A PCR test is highly recommended following a positive at home or antigen test to confirm COVID-19 infection.

Please complete the survey below to receive a verification letter of your self reported positive test. It is very important that you take precautions to prevent the spread of your illness to others. Therefore, you are requested to remain in isolation from others at your place of residence. Additionally, TCHD requests that you notify anyone that you have been in close contact with starting 48 hours prior to when your symptoms started up until the day you began isolating away from others. A close contact is anyone you were within 6 feet of for at least 15 minutes in a 24-hour period.

We appreciate your time and assistance in completing this information. If you have any questions, please contact us at 417-334-4544 ext. 577.

Thank you

First Name*
Last Name*
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Unit/Apt#

CityState / Province

Postal / Zip Code
Sex*

MaleFemaleTransgenderPrefer not to answerOther
Where was this test performed?*

At homeAt the doctor's officeAt a clinicAt workAt schoolOther
Which Doctor's Office?
Which clinic?
Did you have a prescription for the test?*

YesNo
What was the Doctor's name?
When did you take the COVID test? (Date & Time)*

MonthDayYear
Date
What type of specimen was collected?*

Nasal/NoseSaliva/MouthBlood sample
Which type of test did you take?*

AntibodyAntigenLAMPPCRI don't know
Antibody - Blood test or finger measures past infection

Antigen - Rapid BinaxNOW ABBOTT COVID test, At home test kits

LAMP - ABBOTT ID NOW machines, available at Walgreens Rapid COVID test and Taney County Health Department COVID test

PCR - Confirmatory swab (Send off swabs through pharmacy, Cox, Mercy COVID-19 tests)
Do you have any of the symptoms below associated with COVID-19?*

Fever > 100.4Felt FeverishChillsShaking (Rigors)Muscle achesRunny noseSore throatChanges in / Loss of taste or smellHeadacheFatigueCough (New or worsening)WheezingShortness of breathDifficulty breathingChest painsNausea or vomitingAbdominal painsDiarrhea (more than 3x in 24 hours)No symptomsI was exposed to someone with COVID-19Other
What was your first date of symptoms or exposure?*

MonthDayYear
Date
NA
FDS
RNADate

MonthDayYear
Date
Have you had a COVID-19 vaccine?*

Yes, two doses of Moderna or Pfizer AND a boosterYes, two doses of Moderna or PfizerYes, one dose of Moderna or PfizerYes, one dose of Johnson & Johnson AND a boosterYes, one dose of Johnson & JohnsonNo
Signature*

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Date
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Self-Reporting COVID-19 Test Results