COVID Self Report Form

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The form is for reporting a COVID positive test or symptoms to the convention for the purposes of exposure notification and data gathering. You are filling out this form and voluntarily submitting information to the convention for these purposes. You can fill this form our at any time during or after our event. If during the event, we may reach out to you immediately in order to assist facilitating exposure prevention.

Mid-Atlantic Anthropomorphic Association, Inc. is not a "Covered Entity" under HIPAA, but we will protect personally identifying information with the same care and diligence that we do our registration information .

Personally identifying information is ONLY collected for the purposes of contacting you if we need clarifying information and/or for any state mandated reporting requirements. Once these purposes are completed, the personally identifying information will be removed from the responses.

Email *

First & Last Name *

This is used to verify your presence at the event.

Cell Phone Number *

If its time-sensitive, we might text you for verification or additional information.

Are you Vaccinated? *

Yes

Did you get a booster shot? *

Yes, More than two weeks before the event.

Yes, but within two weeks of the event.

Did you download and enable the Virginia COVIDWISE contact tracing app or enable the exposure notification settings in your phone? *

If you did, dont forget to report your positive test results or symptoms to the app.

Yes, I had a contact tracing app enabled before the event.

Yes, I enabled the contact tracing app at registration / During the event.

If no, are you using any other contact tracing app and which one?

On what date was your test? *

Date of the test itself.

YYYY

What date did your receive your test results? *

This should be the date you actually learned of the results.

YYYY

What kind of test did you take?

Provider / lab administered PCR test

Provider / lab administered antigen / rapid test

At-home antigen / rapid test.

Clear selection

Are you experiencing any symptoms? *

Yes

If yes, on what date did your symptoms begin?

YYYY

Is there any other information about your testing and symptoms that we should know (i.e. timeline, multiple tests, hospitalized, etc)

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