At Home COVID Test Self-Report for Oneida County

This form is for individuals who live in Oneida County, Wisconsin to confidentially report their positive COVID-19 at-home results and results for their children. Please complete the information below.

Please note that this is for residents of Oneida County, Wisconsin only. We do not have the capacity to forward reports to other health departments.

Please only report results for yourself or your dependent children here.

Please do not report at-home test results for employees here. If your employee had a positive at-home test, encourage them to complete this form themselves and/or call the Oneida County Health Department at 715-369-6111, dial 0 to reach the front desk.

Thank you for your partnership in responding to COVID-19.

1. Who tested positive for COVID-19?

Name*

First NameMiddle NameLast Name

Date of Birth*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Gender*

Ethnicity*

Race*

Preferred language if other than English

Is this report for you or your child*

Parent or Legal Guardian Name

Test Result*

Date of positive test*

Date

Name/Brand of test (if known)

Did the person who tested positive have symptoms or were they a close contact to someone with COVID-19?*

SymptomsClose Contact

Date symptoms started (if applicable)

Date

Symptoms (select which one(s) apply)?*

If other symptoms, please specify

Are you a ... (select which one applies)?*

Healthcare WorkerStudentTeacherNone of the above

Do you need a work/school release?*

YesNo

Name of workplace or school

COVID Vaccine Status

Please certify your identity*

By checking this box, you are certifying that you are the individual about whom this report is being made or are authorized by law to make this report on behalf of the individual that this report is about.

Do you have another person to add?*

YesNo

At Home COVID Test Self-Report for Oneida County - WISCONSIN RESIDENTS