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COVID-19 Positive Case Reporting Form

Please complete the form below. Required fields marked with an asterisk *

Confirmed/Suspected Case Demographic Data

Ethnicity (Confirmed/Suspected Case)*
Answer Required
Race (Confirmed/Suspected Case)*
Answer Required
Sex (Confirmed/Suspected Case)*
Answer Required
Phone Number Type of Point of Contact*
Answer Required

Disease/Symptom Data

Current Symptoms (day form completed):*
Select All that Apply
Answer Required

Hospitalization and Clinic Data (If Available)

Hospitalization Status:
Answer Required
Confirmation Email