COVID-19 General Public Self-Report Form & Isolation Calculator

This form is intended to collect self-reported information from COVID-19 positive individuals seeking return dates and/or a letter for work. Test results will not be verified by the Livingston County Health Department (LCHD). Your dates/letter will auto-populate upon completion of this form.

This tool is not intended for seeking medical care or COVID-19 treatment. Due to increased caseload and reporting, LCHD will not be following up with you regarding your submission. Please contact your healthcare provider to discuss medical care and COVID-19 treatment options.

If the COVID-19 positive individual is enrolled in or works at a Livingston County school/daycare, use these reporting forms instead: https://survey.alchemer.com/s3/6359915/UPDATED-COVID-19-Self-Report-Form

1. Legal first name of COVID positive person *This question is required.

2. Legal last name of COVID positive person *This question is required.

3. Date of birth of COVID positive person *This question is required. This question requires a valid date format of MM/DD/YYYY.

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4. Parent/Guardian full name (if reporting for a minor)

5. Phone number (numbers only - area code and phone number) *This question is required. This question requires a valid number format.

6. Email

9. Job Industry *This question is required.

10. Job Position/Role

11. Enter date of symptom onset or date of test (if no symptoms) *This question is required. This question requires a valid date format of MM/DD/YYYY.

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12. Type of test (If multiple tests were conducted, indicate the earliest positive test type) *This question is required.

13. Attach positive test results. Allowable files include: png, gif, jpg, jpeg, doc, xls, docx, xlsx, pdf, and txt.

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