EmailMeForm
First and Last Name of Person Who Tested Positive
*
First and Last Name of Guardian (if applicable)
Date of Birth
*
Address
*
Street Address
City
State / Province / Region
Postal / Zip Code
Phone Number
*
Email Address
*
Race
*
Please select
White
Black
American Indian or Alaska Native
Asian
Native Hawaiian or Pacific Islander
Choose Not to Answer
Other
Gender
*
Please select
Male
Female
Other
Choose Not to Answer
Test Name
*
Test Date
*
First Date of Symptoms
*
Symptoms (can select multiple)
*
Fever
Chills
Muscle aches
Runny nose
Sore throat
Cough
Nausea or Vomiting
Headache
Fatigue
Diarrhea
Loss of taste or smell
Difficulty Breathing
Other
Vaccination Status
*
Please select
Vaccinated
Not Vaccinated
Person who tested positive
*
student at a local school district
guardian of a student who attends a local school district
college student
none of the above
Employer
*
School District
*
Has the School District been notified of this positive result?
*
Please select
Yes
No