Positive At-Home Test Report Form
Please complete the survey below to report your positive at-home test results.
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Type of COVID-19 At-Home Test
Please Select
BD Veritor System Rapid Antigen Test
BinaxNOW Antigen Test
BinaxNOW Antigen Card Home Test
CareStart Antigen Test
Celltrion DiaTrust Antigen Test
Ellume Antigen Home Test
Flowflex Antigen Home Test
iHealth Antigen Rapid Test
InteliSwab Antigen Rapid Test
QuickVue Antigen Test
InBios Internaitonal Antigen Test
Detect COVID-19 Home Test
Cue COVID-19 Home Test
Lucira COVID-19 Home Test Kit
Kroger Health COVID-19 Home Test
EmpowerDX COVID-19 Home Test Kit
Everlywell COVID-19 Home Test Kit
GetMyDNA COVID-19 Home Test Kit
Color Health, Inc. COVID-19 Home Test Kit
Phosphorous COVID19 Home Test
LetsGetChecked COVID-19 Home Test
SalivaDirect COVID-19 Home Test
Gravity Diagnostics COVID-19 Home Test
AssuranceCOVID-19 Home Test
SynergyDx COVID-19 Home Test
Viracor COVID-19 Home Test
Clinical Enterprise COVID-19 Home Test
WREN Laboratories COVID-19 Home Test
Amazon COVID-19 Home Test
Pixel by LabCorp COVID-19 Home Test
Pinpoint by Phosphorous COVID-19 Home Test
Other
All Antigen Tests contain "Antigen" in list name. All PCR Tests contain "COVID-19" in list name. If test name is not found, please select "Other".
If OTHER Test was used, please share the Brand Name of COVID-19 At-Home Test
Positive Test Date
-
Month
-
Day
Year
Date
Are you fully-vaccinated against COVID-19? (Fully-vaccinated means you have received 1 dose of J&J OR your 2nd dose of Moderna/Pfizer more than 2 weeks prior to your positive test.)
Yes, I am fully-vaccinated
Yes, I am fully-vaccinated AND received a Booster dose
No, I am not fully-vaccinated
Submit
Should be Empty: