Reporting an at Home Positive COVID-19 Test Result

Reporting a COVID-19 At Home Test Result (Riley county, KS & Surrounding Areas)

1. What day did you take the test? (Format required: MM/DD/YEAR, for example 01/19/2022) This question requires a valid date format of MM/DD/YYYY.

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2. What was the test result? *This question is required.

• Positive
• Negative
• Invalid

3. Contact Information: *This question is required.

First Name

Last Name

Street Address & Apt #

City

State

Zip

Phone Number

4. Date of Birth: 
(Format required: MM/DD/YEAR, for example 01/19/1992) *This question is required. This question requires a valid date format of MM/DD/YYYY.

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5. Biological Sex:

• Male
• Female

6. Email: This question requires a valid email address.

7. Have you been vaccinated?

• No
• Yes, only 1 dose (not completed a full series)
• Yes, Fully vaccinated (I have not received a booster dose)
• Yes, Fully Vaccinated and received a booster Dose
• I prefer not to answer

8. Were you a direct close contact of someone who tested positive? 

• Yes
• No
• Unknown

9. You can list any symptoms below, potential exposure locations, and provide any additional info. (These responses will be monitored several times a week)