Form Test


    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