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.
After submitting information related to your home test below, you should see a link pop up to get your isolation orders. You can also get quarantine orders at that link for any contacts. More information can also be found on the Steuben County Public Health Isolation and Quarantine Orders page.
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 *
If you have a picture, please upload the image of your positive 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
Second 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