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At Home (over-the-counter) COVID Test- Positive Test Report.
Please use this form to self-report positive results from at-home COVID-19 antigen tests to the Henry/Stark County Health Department and the Office of Emergency Management. For use by Henry & Stark County Residents ONLY.
Name
*
First Name
Last Name
Suffix
Date of Birth
*
-
Month
-
Day
Year
Date
Age
Phone Number (Cell # Preferred for Text Messaging)
*
Please enter a valid phone number.
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Race
*
American Indian/Alaskan Native
Asian
Black/African American
Native Hawaiian/other Pacific Islander
White
Prefer not to answer
Other
Are you Hispanic or Latino?
*
Yes
No
Prefer not to answer
Sex Assigned at Birth
*
Female
Male
Non-binary
Prefer not to answer
On what date did you test POSITIVE for COVID-19
*
-
Month
-
Day
Year
Date
Which over-the-counter COVID-19 test was used?
*
Please Select
CareStart COVID-19 Antigen Home Test
iHealth COVID-19 Antigen Rapid Test
BD Veritor At-Home COVID-19 Test
SCoV-2 Ag Detect Rapid Self-Test
BinaxNOW COVID-19 Antigen Self Test
InteliSwab COVID-19 Rapid Test
Celltrion DiaTrust COVID-19 Ag Home Test
QuickVue At-Home OTC COVID-19 Test
Flowflex COVID-19 Antigen Home Test
Ellume COVID-19 Home Test
Other/Unknown
On what date did your symptoms begin? If you do not have ANY symptoms of COVID (asymptomatic), please use the date you tested positive.
*
-
Month
-
Day
Year
Date
What is your COVID Vaccination Status?
*
Not Vaccinated
Partially Vaccinated
Fully Vaccinated (Without Booster)
Fully Vaccinated and Boosted
Prefer not to answer
If Fully Vaccinated, Please Select Which Best Applies:
Fully Vaccinated with Moderna
Fully Vaccinated with Pfizer
Fully Vaccinated with J & J
Fully Vaccinated & Boosted with Moderna
Fully Vaccinated with Moderna & Boosted with Pfizer
Fully Vaccinated & Boosted with Pfizer
Fully Vaccinated with Pfizer & Boosted with Moderna
Fully Vaccinated with J & J and Boosted with Moderna
Fully Vaccinated with J & J and Boosted with Pfizer
Other
Prefer not to answer
Unknown
Are you a Resident or Employee of a congregate living setting? (For example: nursing home, group home, prison, jail or active military)
Yes
No
Are you a Health Care Worker or First Responder?
Yes
No
Please provide information about those you share a home with. (Household Contacts)
Household Contact # 1 - Name
First Name
Last Name
Suffix
Household Contact # 1 - Age
Household Contact # 1 - Phone Number
Please enter a valid phone number.
Household Contact # 2 - Name
First Name
Last Name
Household Contact # 2 - Age
Household Contact # 2 - Phone Number
Please enter a valid phone number.
Household Contact # 3 - Name
First Name
Last Name
Household Contact # 3 - Age
Household Contact # 3 - Phone Number
Please enter a valid phone number.
Household Contact # 4 - Name
First Name
Last Name
Household Contact # 4 - Age
Household Contact # 4 - Phone Number
Please enter a valid phone number.
Household Contact # 5 - Name
First Name
Last Name
Household Contact # 5 - Age
Household Contact # 5 - Phone Number
Please enter a valid phone number.
Household Contact # 6 - Name
First Name
Last Name
Household Contact # 6 - Age
Household Contact # 6 - Phone Number
Please enter a valid phone number.
Do you have more than six (6) household contacts to report?
*
Yes, please contact me.
No, I have listed them all above.
I do not have any household contacts.
Do you or your family need assistance with any of the services listed below? If you do, please select all those that apply. Henry County Officials will be happy to forward your request(s) to the appropriate local agency, who will then contact you.
Utility Bill Assistance
Housing Assistance (Rent or other housing related)
Water/Sewer Bill Assistance
Food Assistance
Not At This Time
Get help when you need it. Hoping mental health problems such as anxiety or depression will go away on their own can lead to worsening symptoms. Would you like to be contacted about available local mental health services?
Yes, Please contact me
Not right now, but I will call (309)852-5272 if I have a need later.
After a Positive COVID Test Result
You should stay home and isolate. Isolation is used to separate people with confirmed or suspected COVID-19 from those without COVID-19. People who are in isolation should stay home until it’s safe for them to be around others. At home, anyone sick or infected should separate from others, or wear a well-fitting mask when they need to be around others. People in isolation should stay in a specific “sick room” or area and use a separate bathroom if available. Everyone who has presumed or confirmed COVID-19 should stay home and isolate from other people for at least 5 full days (day 0 is the first day of symptoms or the date of the day of the positive viral test for asymptomatic persons). They should wear a mask when around others at home and in public for an additional 5 days. People who are confirmed to have COVID-19 or are showing symptoms of COVID-19 need to isolate regardless of their vaccination status.
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