SBC COVID-19 Rapid Test Report Form

San Benito County Public Health Services
COVID-19 Rapid Test Report Form
Person Being Tested*

First NameLast Name
Phone*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Sex:*

MaleFemaleNon-Binary
Test date (mm/dd/yyyy)*

MonthDayYear
Date
Exposure Date(Last date of close contact to a confirmed case):

MonthDayYear
Date
Exposure Date Unknown

Unknown
Symptoms (check all that apply)

Fever (>100.4°F, 38°C)Subjective fever (feverish)CoughSore throatBody achesAbdominal painDiarrheaHeadacheNauseaVomitingBody achesChillsLethargy/fatigueLoss of smellLoss of tasteRunny noseShortness of breathDifficulty breathingDermatologic FindingOther
Symptom Start date:

MonthDayYear
Date
No Symptoms
Chronic Conditions (Check all that apply)

AsthmaCardiovascular DiseaseChronic Lung DiseaseStroke, DVTHypertensionDifficulty DiabetesChronic Kidney DiseaseNeurological/Neuro-DevelopmentalObesityChronic Liver DiseaseImmunocompromisedCancerCurrent SmokerFormer SmokerPregnantNoneUnknownOther
Primary Language (check one)

EnglishSpanishOther
Ethnicity (check one)

Hispanic/LatinoNon-Hispanic/Non-LatinoUnknown
Race (check one)

African-American/BlackAmerican Indian/Alaska NativeAsianPacific IslanderWhiteUnknownOther
Vaccination History
Has person received COVID-19 Vaccine?*

YesNoUnknown
Dose #1 Date:

MonthDayYear
If unknown leave blank
Dose #1 Type:

ModernaPfizerOtherUnknown
Dose #2 Date:

MonthDayYear
If unknown leave blank
Dose #2 Type:

ModernaPfizerUnknownOther
Dose #3 Date:

MonthDayYear
If unknown leave blank
Dose #3 Type:

ModernaPfizerUnknownOther
Test Type

Abbott BinaxNOWBD VeritorQuidel SofiaOtherUnknown
TEST RESULT

NegativePositiveIndeterminateNot Tested
Employer/Agency
Name of Person Completing Form:

First NameLast Name
Phone Number of Person Completing Form
Should be Empty:

San Benito County Public Health Services

COVID-19 Rapid Test Report Form

Vaccination History