Home Test Report

Please use this secure form to report information about your positive COVID-19 home test results to District Health Department #10. The data collected is maintained according to HIPAA standards. Questions with a red asterisk at the end are required. If you have any questions, you can call us at 231-305-8675 or email info@dhd10.org . If you have any emergency symptoms like trouble breathing, chest pain, or severe weakness, seek medical care immediately. Follow up with your health care provider as needed. See https://www.dhd10.org/covid-19-now-what/ for more resources.

1. What is your name? (Please include first and last) *This question is required.

2. What is your date of birth? *This question is required. This question requires a valid date format of MM/DD/YYYY.

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3. What county do you live in? (If your county is not in the drop-down menu, District Health Department #10 is not considered your local health department. Please check your local health department website for home test reporting procedures.) *This question is required.

4. What date did you test positive on a home test? *This question is required. This question requires a valid date format of MM/DD/YYYY.

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