Antigen Reporting

1 Why report home antigen test results

This form is to be used by individuals who live or work in Sonoma County to report the results of COVID-19 testing done in the home to the SoCo Public Health Division. Please do not complete this form if you received testing at a healthcare or testing site, only report testing you administered yourself.

We will use this information for tracking testing by Sonoma County residents just like we track testing done by medical providers and COVID testing sites. The information you report will be used by Sonoma County Public Health in the same manner as tests conducted by a medical provider or COVID testing site as part of our public health oversight.

We will only disclose information you provided in this form to accomplish our duties as a Public Health Authority, if essential to the completion of the objectives of the County’s COVID-19 testing or surveillance program and as required by law. We will report results to relevant State and schools testing tracking systems as required by/under Title 17, California Code of Regulations (CCR) 2500, 2593, 2641.5-2643.20, and 2800-2812 Reportable Diseases and Conditions

What is your preferred language?

If Other, please answer below

What is your reason for taking this COVID test?

If Other, please answer below

2 Demographic Information

You may enter initials rather than the full name of the person being tested if you would like to submit this information anonymously

Name of the person being tested*

First NameLast Name

Date of Birth of the person being tested*

Date

Check below if you would prefer to only enter the year of birth.

Enter year only

Year of birth

Gender of person being tested

If Other, please answer below

Race of person being tested

If Other, please answer below

Latinx status of person being tested

Email Address for use in communicating with you about your COVID test

example@example.com

Phone Number for use in communicating with you about your COVID test

Please enter a valid phone number.

Home address of the person being tested

Street Address

Street Address Line 2

CityState

Zip Code

3 Testing Information

Date test was taken*

Date

Test Result: (Note: If you are reporting a positive result, Sonoma Public Health recommends you also notify your Primary Care Provider)*

PositiveNegativeUnsure

Did the person being tested have any symptoms?*

YesNo

What is the usual occupation of the individual being tested?

What is the name of the workplace/employer?

Did the individual being tested attend, or work at a school, childcare, or other youth programs (such as after-school care or youth sports) during their infectious period? (infectious period is defined as up to 48 hours prior to symptom onset or date of positive test, whichever came first)*

YesNo

Does the individual taking the test live in a group living setting?*

YesNo

Name of setting

Does the individual taking the test work at a healthcare or residential facility, or other congregate or group living setting?*

HealthcareCongregate livingNeither

What is the name of the facility?

Does the individual taking the test receive care from a home health care or home hospice agency?*

YesNo

What is the name of the facility?

Did you receive this home test for free?

YesNoUnsure

How did you receive your test?

If Other, please answer below

Please note: This test may not count for employers or travel. You may need additional lab testing depending on the requirements of your employer or travel airline or destination.
Privacy Statement: We may collect personally identifiable information as required either by law or in order for us to provide a requested service. We have privacy and security measures in place to safeguard personally identifiable information.

Community Report of Home Antigen Results