Full Name Address Date of Birth Phone Number Upload Drive License and Utility bill (Maximum File Size is 2MB) 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
