Fillable Report Covid Results (Town of Westerly)

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Report Covid Results (Town of Westerly)

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The Report Covid Results (Town of Westerly) form is 5 pages long and contains:

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  • 64 check-boxes
  • 40 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Town of Westerly

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Report Covid Results
Organization Name:
Organization City:
Test Location
*
Patient First Name
*
Patient Last Name
Address
Street
City State/Province
Zip/Postal Code Country
*
Birth Date
*
Gender
Female
Male
Other
Westerly Police Department
Westerly, RI
Westerly Police Dept.
*
Race (Select all that Apply)
American Indian or Alaska Native
Black or African American
White
Asian
Native Hawaiian or Other Pacific Islander
Not Specified
Don't Know
Declined
Refused to answer
Not Asked
Other Race
No Information
*
Hispanic Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Don't Know
Declined
*
Nationality (Select all that Apply)
American
Asian
Cambodian
Cape Verdean
Chinese
Columbian
Congolese
Dominican
English
Ethiopian
Filipino
French
German
Ghanaian
Guatemalan
Hmong
Indian
Irish
Italian
Korean
Laotian
Lebanese
Liberian
Mexican
Nigerian
Polish
Portuguese
Puerto Rican
Russian
Salvadoran
Scottish
Somalian
Syrian
Taiwanese
Vietnamese
Other
*
Primary Language
*
Phone Number (1112223333)
*
Email
Affiliate with Education Setting
Yes
No
Unknown
Education Setting
Childcare
K12
Higher Ed (University/College)
Higher Ed (Technical)
Higher Ed (Military)
Help Text: Please complete the School Name and Learning Style Fields below if you are reporting results for
a patient associated with the K12 school. This information is important for epidemiological analysis and case
investigation.
School Name
English
School Affiliation
Student
Staff
Other
Learning Style
In Person
Virtual
Hybrid
COVID-19 SYMPTOMS
Select all that Apply
No Symptoms
Cough
Shortness of breath or difficulty breathing
Fever
Chills
Muscle pain
Sore Throat
Headache
Nausea
Vomiting
Diarrhea
Runny nose
Fatigue
Recent loss of taste
Recent loss of smell
Congestion
Symptom Onset Date (01/01/2020 or Jan 1, 2020)
*
Test Type
BINAXnow
*
Date test completed (01/01/2020 or Jan 1, 2020)
*
Test Result
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Report Covid Results (Town of Westerly)

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Completed 19 January 2021

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