Covid-19 Positive Home Test Reporting

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If you or your child have tested positive for COVID-19, use this form to report this test and results.People with COVID-19 should isolate for 5 days and if they are asymptomatic or their symptoms are resolving (without fever for 24 hours), follow that by 5 days of wearing a mask when around others to minimize the risk of infecting people they encounter. If you are still fevered or symptomatic, stay in and isolate until that is gone for 24 hrs, wearing a mask through the remaining days until 10 days.
Completely this form allows for contact tracing.

Name of Postive Patient *

Date of Birth *

YYYY

If patient is a minor please provide guardian name and phone number.

Phone number *

Address *

Date of COVID test *

YYYY

Type of COVID test *

At Home Test- Proctored (done using an app or with a health professional)

At Home Test unproctored

Testing Site Test

Date of Onset of Symptoms

If asymptomatic, skip question.

YYYY

School or Place of Employment *

Submit

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