HAMPTON UNIVERSITY
COVID-19 TEST FORM
Revised 5/20/2021
Last Name:
Date of Birth: Age: Sex: Race: Ethnicity:
Address:
Staff Residence County:
City:
State: Zip Code:
Unique HUID #:
Cellphone Number:________________Work Number:__________________ Home number:_______________
Hampton University email: __________________________________________________________________
Personal Email: ___________________________________________________________________________
Have you been tested for COVID-19 before?
Do you work in a healthcare facility with direct patient contact?
Do you live in a congregate care/living setting?
Do you have symptoms for COVID-19?
UNK
UNK
UNK
UNK
List any symptoms:
Were you hospitalized at the time of the COVID-19 test?
Were you in the ICU at the time of testing for COVID-19?
Are you pregnant? PREGNANT
UNK
UNK
NOT PREGNANT UNK
Vaccination History
Have you been vaccinated? YES______ NO______UNK_______
If yes, which vaccine did you receive: ____Moderna ______Pfizer _________Johnson & Johnson
What were the dates of your vaccination: _______________First shot __________________Second shot
REPORTER INFORMATION
Date Test Ordered: Date Specimen collected: _
Clinic: Hampton University Covid-19 Lab Address: Research II Phone: (757) 728-6242 CLIA# _49D2201186
City: Hampton State: VA Zip Code: 23668 Laboratory Director Name:
Henry Bell, MD
NPI#:1457326555
LABORATORY TESTING
Name of the test ordered: Abbott Ag Test-SARS-CoV + SARS-CoV-2 Ag- 952093 Device Identifier: Binax NOW COVID - 19 Ag Card
Specimen Source: Nasal Swab - 87181001
Specimen Identification number: ____________________________________
Test Performed: Abbott Binax Now COV-19 Ag Card 94558-4_________________________________________________________________
Test Results: _____________________________________________________ Test Results Date:___________________________________________
Tester Initials:______________________________________________ Report Date: _______________________________________________
