Positive At-Home Test Report Form

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
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
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