Form Test


PATIENT RACE (REQUIRED BY HHS AND CDC)

American Indian or Alaskan Native (AI)Asian (AS)Black or African American (B)Native Hawaiian or Other Pacific Islander (PI)White (W)Multiple/Other (O)

PATIENT ETHNICITY (REQUIRED BY HHS AND CDC)

Hispanic/Latino (H)Non-Hispanic/Latino (N)Unspecified/Not Given/Refused (U)

COVID-19 CLINICAL HISTORY (REQUIRED BY HHS AND CDC)

First Test?
YESNOUNKNOWN

Employed in Healthcare?
YESNOUNKNOWN

Symptomatic as defined by CDC?
YESNOUNKNOWN

If YES, then date of symptom onset:

Hospitalized for COVID-19?
YESNOUNKNOWN

ICU for COVID-19?
YESNOUNKNOWN

Resident in congregate care setting?
YESNOUNKNOWN

Pregnant?
YESNOUNKNOWN