Home Testing - Orleans

Orleans County, NY

Positive COVID-19 Home Test Reporting Form

Please follow the manufactures directions to complete your at-home COVID-19 test.

Please use the form below to report a positive result from a COVID-19 test taken at home. A new form must be completed for each household member who tests positive. A picture of the test result must be taken within 15 minutes of the manufacturer’s directions processing end time. The name of the individual who was tested, the date and time the test was taken should be written legibly on the test. If there are any missing sections that are required on the form below, the form will be invalid.

A photo image of your positive test result is REQUIRED. Positive test results are required to be submitted within 24 hours of completing the at-home test. Do NOT submit this form if you tested negative.

* Required Fields

First Name

Middle Name

Last Name

Month of Birth

Day of Birth

Year of Birth

Gender

Date of COVID Test

Did you test positive for COVID-19

Yes

COVID-19 Test Brand Name / Type

Phone Number

Street Address - Line 1

Address - Line 2

City

State

Zip Code

Use the button below to upload a photo of your POSITIVE test result only. Legibly write the individuals name, the date, and the time the test was taken directly on the test. Max file size: 5 MB. Allowed file types: JPG, JPEG, GIF, PNG.

I have written the name of the individual who was tested, the date and time the test was taken legibly on the test.

Yes

I attest that the information on this form and the attached positive test result is mine or my minor child whose name is listed. All information is true and accurate.

Yes

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Home Testing – Orleans

Orleans County, NY

Positive COVID-19 Home Test Reporting Form

GENESEE COUNTY

ORLEANS COUNTY

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