Positive COVID-19 Home Test Reporting Form

Please follow the manufacturer’s instructions to complete your at-home COVID-19 test. Please remember to read the test results in the specified timeframe listed in the instructions for the at-home COVID-19 test.

If your test is positive use the form below to report your test results. A new form must be completed for each household member who tests positive. If there are any missing sections that are required on the form below, the form will be invalid.

*Do NOT submit this form if you tested negative.*

Please isolate immediately and you will receive a call from a case investigator regarding your positive test. Depending on our caseload, it may be up to three (3) days before you are called. Please answer the phone so we can reduce the spread of COVID-19.

* Required Fields

Name *

First Name Last Name

Date of Birth *

Email *

example@example.com

Phone Number *

Please enter a valid phone number.

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

County of Residence *

Allegany

Are you an Employee, or Student, of a Pre-K through 12th Grade School? *

Yes No

Name of School/School District *

Date Swabbed/Test Taken *

Date Results Read *

Allegany County Department of Health