Full Name

Email ID

Address

Date of Birth

PhoneNumber

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PATIENT RACE (REQUIRED BY HHS AND CDC)

American Indian or Alaskan Native (AI)Asian (AS)Black or African American (B)Native Hawaiian or Other Pacific Islander (PI)White (W)Multiple/Other (O)

PATIENT ETHNICITY (REQUIRED BY HHS AND CDC)

Hispanic/Latino (H)Non-Hispanic/Latino (N)Unspecified/Not Given/Refused (U)

COVID-19 CLINICAL HISTORY (REQUIRED BY HHS AND CDC)

First Test?

YESNOUNKNOWN

Employed in Healthcare?

YESNOUNKNOWN

Symptomatic as defined by CDC?

YESNOUNKNOWN

If YES, then date of symptom onset:

Hospitalized for COVID-19?

YESNOUNKNOWN

ICU for COVID-19?

YESNOUNKNOWN

Resident in congregate care setting?

YESNOUNKNOWN

Pregnant?

YESNOUNKNOWN