COVID-19 Positive Home Test Report
This form is intended for people that have tested positive with an At-Home COVID-19 test kit and live in Platte County, Missouri. This does not replace any investigation call that may be placed by a Platte County Health Department disease case investigator. Any information reported here is kept secure. Once the form is completed, you will be directed to the CDC for updated guidance.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
Male
Female
Non-binary/third gender
Prefer not to say
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Date of Symptom Onset
*
Date of Test
*
Submit
Should be Empty: