COVID-19 Self Reporting Form

COVID-19 Self Reporting Form

Please complete all fields as they apply to you. Fields marked with an asterisk (*) are required fields.
Our clerical staff is working diligently to send out quarantine orders. Due to the volume of positive home tests, it may take up to 48 hours to receive your order. Thank you for your patience and understanding!
Name *

First Name Middle Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
Email *
Please enter a valid email address.
Date of Birth *

Month Day Year
Date
Date of Positive COVID-19 Test *

Month Day Year
Date
COVID-19 Test Brand Name/Type *
Please Upload an Image of Your Test Result: *

Please upload an image of your positive test result. Files must be less than 4 MB. Allowed file types: gif, jpeg, jpg, pdf, png
Cancel of
Date of Symptom Onset?

Month Day Year
Date
Are you vaccinated? *

Yes No
Name of Vaccine Received

Johnson & Johnson Moderna Pfizer
First Vaccination Date

Month Day Year
Date
Second Vaccination Date

Month Day Year
Date
Booster Date, If Completed

Month Day Year
Date
Do you work for a school or attend a school (K-12)?

Yes No
Household Contacts
Name

First Name Last Name
Contact is staying separated from positive household member?

Yes No
Contact is showing COVID-19 symptoms?

Yes No
Contact is vaccinated?

Yes No
Date of most recent contact with positive member?

Month Day Year
Date
Does this contact work for a school or attend a school (K-12)?

Yes No
Name

First Name Last Name
Contact is staying separated from positive household member?

Yes No
Contact is showing COVID-19 symptoms?

Yes No
Contact is vaccinated?

Yes No
Date of most recent contact with positive member?

Month Day Year
Date
Does this contact work for a school or attend a school (K-12)?

Yes No
Name

First Name Last Name
Contact is staying separated from positive household member?

Yes No
Contact is showing COVID-19 symptoms?

Yes No
Contact is vaccinated?

Yes No
Date of most recent contact with positive member?

Month Day Year
Date
Does this contact work for a school or attend a school (K-12)?

Yes No
Name

First Name Last Name
Contact is staying separated from positive household member?

Yes No
Contact is showing COVID-19 symptoms?

Yes No
Contact is vaccinated?

Yes No
Date of most recent contact with positive member?

Month Day Year
Date
Does this contact work for a school or attend a school (K-12)?

Yes No
Name

First Name Last Name
Contact is staying separated from positive household member?

Yes No
Contact is showing COVID-19 symptoms?

Yes No
Contact is vaccinated?

Yes No
Date of most recent contact with positive member?

Month Day Year
Date
Does this contact work for a school or attend a school (K-12)?

Yes No
Name

First Name Last Name
Contact is staying separated from positive household member?

Yes No
Contact is showing COVID-19 symptoms?

Yes No
Contact is vaccinated?

Yes No
Date of most recent contact with positive member?

Month Day Year
Date
Does this contact work for a school or attend a school (K-12)?

Yes No
Please verify that you are human *
Should be Empty:

COVID-19 Self Reporting Form

Household Contacts