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New Canaan Health Department
Positive Home Test Results
* Indicates required question
First Name
*
Your answer
Last Name
*
Your answer
New Canaan Address
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Phone number -Best number to be reached during daytime hours.
*
Your answer
What is your Vaccination Status
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One dose of mRNA vaccine - Pfizer or Moderna
Two doses of mRNA vaccine - Pfizer or Moderna
One dose of J&J
Have received all doses in series plus booster
Unvaccinated
Received different vaccine than those listed (Out of Country)
Required
How would you describe your severity of symptoms?
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Asymptomatic (no symptoms)
Minor (runny nose, post nasal drip)
Moderate (congestion, fever, body aches, sore throat)
Severe ( Hospitalization)
Required
Did you seek additional testing to confirm home test positive
*
Choose
Yes
No
Date of Positive Test
*
MM
/
DD
/
YYYY
Have you traveled or attended a gathering in the last 10 days?
*
Choose
Yes
No
Submit
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