COVID-19 Positive Test Self Report
Please complete this form if you have tested positive with an at home COVID test kit. This form is voluntary and not required. Answer the questions to the best of your ability.
Please enter a valid phone number.
Street Address Line 2
State / Province
Postal / Zip Code
Are you currently pregnant?
Date Test Performed
What is the name of the test you took?
Do or did you have symptoms
Date symptoms started
Select ALL symptoms you experienced
Fever greater than 100.4
Change to taste OR smell
Shortness of breath
Nausea or vomiting
Are you vaccinated against COVID-19
Which vaccine did you receive
How many doses of the vaccine have you received?
In the last 10 days prior to onset of symptoms or positive test
Attend an event/meeting with 10 or more people
Travel by mass transit (train/bus/airplane)
Visit or work in a congregate setting such as: school, hospital/clinic, manufacturing plant, long term care facility
Was a close contact to a known COVID-19 case
Should be Empty:
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