Self-Reporting Survey for Positive COVID-19 Test Result Question Title * 1. Are you reporting positive results for yourself or someone else? Myself Someone else Question Title * 2. Provide the name of the individual tested. Question Title * 3. If you were not the individual tested, please provide your name. Question Title * 4. What is the date of birth of the individual tested? Date / Time Date Question Title * 5. Please provide the following information for the individual that tested positive. Address City State Zip Code Question Title * 6. On what date was the test done? Date / Time Date Question Title * 7. What is your phone number? Question Title * 8. Please submit a photo of the positive test result you received. PDF, DOC, DOCX, PNG, JPG, JPEG file types only. Choose File Choose File No file chosen Remove File Please submit a photo of the positive test result you received. Done