Vermont COVID-19 Self-Test Result Reporting Form

Use this form to report results from taking an at home COVID-19 test, also known as an over the counter test or self test. Your response is confidential, and reporting your test result helps the Health Department understand how many Vermonters are being tested for COVID-19 and how the virus is spreading in our communities. If your test result is positive, the Health Department will use the information you provide for contact tracing. The Health Department will not contact you if your test result is negative.

Name of Person Tested *This question is required.

First Name

Last Name

Date of Birth of Person Tested *This question is required. Please use the format MM/DD/YYYY. This question requires a valid date format of MM/DD/YYYY.

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Sex of Person Tested *This question is required.

Home Address and Phone Number of Person Tested

Street Address

City *This question is required.

Zip

Phone Number

Race of Person Tested

Ethnicity of Person Tested

Test Performed *This question is required.

Test Performed *This question is required. Please enter the name of the test as it appears on the box.

Date of Test *This question is required. This question requires a valid date format of MM/DD/YYYY.

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Your test result is positive. Please visit www.healthvermont.gov/covid19positive for information on immediate steps to take to protect yourself and others.

Your test result is negative. If you are experiencing symptoms and the test you took was an antigen test, it is recommended that you confirm this result with a PCR test. Please visit https://www.healthvermont.gov/testing to find a free COVID-19 test location.

Your test result is inconclusive or invalid. It is recommended to be re-tested.