Registration for BinaxNOW Antigen Testing

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You are requesting a BinaxNOW rapid antigen test administered by Gonzaga Preparatory School. Please complete the following registration form for yourself or for your student, to begin the testing process. Facilities administering point-of-care (POC) testing for COVID-19 must report all COVID-19 testing results to the Washington State Department of Health (DOH) and/or Spokane Regional Health District (SRHD). WAC 246-101. These registration questions are required by WADOH.

Email *

Building (where your student attends or where you work). *

Gonzaga Preparatory High School

Date *

YYYY

Last Name *

First Name *

Middle Initial *

Sex at Birth *

Female

Male

Neither/Other

Unknown

Date of Birth *

YYYY

Age *

Affiliation to Facility *

Staff

Visitor

Student

Street Address *

City *

State *

Washington

Idaho

Other

Zip Code *

County *

Phone Number *

Are you pregnant? *

Yes

Did you have symptoms of COVID-19 at the time of testing? *

Yes

Patient Race *

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Pacific Islander

White

Other

Unknown

Specify other race

Patient Ethnicity *

Hispanic or Latino

Non Hispanic or Latino

Unknown

COVID-19 diagnosed in the last 90 days? *

Yes

Exposed to a COVID positive person in the last 2 weeks? (together 15 minutes, less than 6 ft apart? *

Yes

Vaccinated for COVID-19? *

Yes - Fully vaccinated

Yes - still need second dose

Send me a copy of my responses.

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