At Home COVID-19 Test Reporting Form

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If you or another individual have received a positive result from an at home COVID-19 test please use this form to report it to the Lenawee County Health Department. This form is protected by HIPAA and no personal health information will be shared with any other party besides the Lenawee County Health Department. If you would prefer to speak to a case manager rather than complete the form, please call 517-264-5226 option 5 and ask for a case manager.

The information gathered from positive tests allows the health department to monitor for health disparities across the county.

To gather more information about home isolation please text 1-855-706-1919 and text LENAWEE. You will be brought to a website with different resources that are available to you. To get more information on the specific topic you are interested in please tap and hold.

First name of the person filling out this form: *

Last name of the person filling out this form: *

Phone number of the person filling out this form: *

Email of the person filling out this form: *

Relationship of person filling out this form to the positive individual *

Self

Parent/Guardian

Friend

Spouse

Other:

First name of the positive individual: *

Last name of the positive individual: *

Phone number of the positive individual: *

Home address of the positive individual: *

What best describes where the positive individual was staying at time of illness onset (or at time of positive test for asymptomatic individuals)? *

Acute care inpatient facility

Apartment

Assisted living facility

Homeless shelter

Hotel

House/single family home

Group home

Long term care facility

Mobile home

Motel

Nursing home

Outside or in a car

Correctional facility

Rehabilitation facility

Other:

Date of birth of the positive individual: *

YYYY

Date of the positive at home test: *

YYYY

Gender of the positive individual: *

Male

Female

Other

Race of the positive individual: *

White/Caucasian

Black/African American

American Indian/Alaskan Native

Hawaiian/Pacific Islander

Asian

Refuse to answer

Other:

Required

Hispanic ethnicity of the positive individual: *

Hispanic/Latino

Non-Hispanic/Latino

Unknown

Refuse to answer

Arab ethnicity of the positive individual: *

Arab

Non-Arab

Unknown

Refuse to answer

Work or school of the positive individual: *

Last day at work or school: *

YYYY

Was the positive individual exposed to COVID-19 before testing positive? *

Yes

Unknown

If yes, where was exposure?

Did the positive individual have symptoms? *

Yes

No (asymptomatic)

If yes, when did symptoms start?

YYYY

If yes, please check all symptoms that the positive individual experienced:

Fever

Chills

Body aches

Runny nose

Sore throat

Cough

Shortness of breath

Nausea

Vomiting

Headaches

Abdominal pain

Diarrhea

Fatigue/Weakness

Congestion

Wheezing

Difficulty breathing

Chest pain

Loss of taste

Loss of smell

Pnuemonia

Seizure

Did symptoms resolve? *

Yes

If yes, when did the symptoms end?

YYYY

Was the positive individual hospitalized? *

Yes

If hospitalized, date of admission into the hospital:

YYYY

If hospitalized, date of discharge:

YYYY

Does the positive individual have any underlying health conditions? If yes, check all that apply: *

No underlying health conditions

Asthma/Reactive Airway Disease

Autoimmune condition

Cancer

Cardiovascular Disease

Chronic Liver Disease

Chronic Lung Disease/COPD/Emphysema

Chronic Renal Disease

Diabetes

Hypertension

Neurologic Disease

Severe Obesity (>40 BMI)

Other Chronic Disease

Other Autoimmune Disease

Psychological/Psychiatric Condition

Disability (Neurological, neurodevelopmental, intellectual, physical, vision or hearing impairment)

Required

Was the positive individual taking any of the following medication when they tested positive? *

None of the following

Aspirin or aspirin-containing products

Chemotherapy

Radiation therapy

Systemic steroids (not inhaled)

Other immunosuppressive medication

Required

Was the positive individual pregnant at the time of the positive test? *

Yes

Unknown

Not applicable

If yes, how many weeks pregnant?

Is the positive individual a current smoker? *

Yes

Is the positive individual a former smoker? *

Yes

Is the positive individual a current vaper? *

Yes

Is the positive individual a former vaper? *

Yes

Does the positive individual currently use drugs or other substances? *

Yes

Did the positive individual formerly use drugs or other substances? *

Yes

Is the positive individual vaccinated? *

Yes

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