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COVID-19 Home Test results
Please use this form only if your home test shows a POSITIVE result for COVID-19.
Name
*
First Name
Last Name
Date of Birth (MM-DD-YYYY)
*
Age TODAY
*
If person is less than 18 years old, Parent's Name:
Primary Language
*
English
Spanish
Other
Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
Email
example@example.com
How many people live at this same address?
*
Name of Employer or School
*
COVID-19 vaccine received
*
1st
2nd
3rd / Booster
4th / 2nd Booster
1st only & Booster(s)
Initial vaccine(s) & multiple boosters
None
Number of previous COVID-19 infections
None
1
2
3
4
5
6
7
8
9
10 or more
Date Symptoms started
*
-
Month
-
Day
Year
Date
Name / Brand of Home or OTC Test
*
Date of Positive COVID-19 Test
*
-
Month
-
Day
Year
Date
Name of Primary Care Provider (PCP; Your Doctor's name)
Check all symptoms you have experienced with this infection
*
NONE (No symptoms / Asymptomatic)
Abdominal pain or cramps
Brain Fog / Confusion
Chills
Cough
Diarrhea
Dizziness / Vertigo
Fatigue
Fever
Headache
Muscle aches or pain
Nausea
Runny nose
Sore or scratchy throat
Shortness of breath (Dyspnea)
New onset of loss of Taste / Smell
Vomiting
Other (None of the symptoms listed)
If you marked the "Other" symptom above, please describe the symptom(s) experienced not yet on our list:
0/50
I acknowledge & understand I am voluntarily reporting a positive COVID-19 Home Test result to the Okanogan County Public Health District (OCPHD) and may be contacted for Contact Tracing purposes.
*
Yes
Send POSITIVE TEST REPORT to the OCPHD
Should be Empty: