Post-Holiday Return to School Home Rapid Antigen Test Reporting

Post-Holiday Return to School Home Rapid Antigen Test Reporting

This form takes three minutes to complete
If you have been instructed by your school to use the Primary.Health reporting platform, use that form instead. Do not report on both this and the Primary.Health reporting form.
- This form is to be used by individuals who attend or work in a Marin County school to report the results of COVID-19 testing done in the home to the Marin County Public Health Department.
- Please do not complete this form if you received testing by a medical provider or COVID testing site. Only report testing you administered yourself with the kits distributed through your school.
- The information you report will be used by Marin County Public Health in the same manner as tests conducted by a medical provider or COVID testing site. We will use information you provide to accomplish our duties as a Public Health authority, if essential to the completion of the objectives of the County’s COVID-19 testing or surveillance program and as required by law.
- We will report results to relevant State and schools testing tracking systems as required by Title 17, California Code of Regulations (CCR) 2500, 2593, 2641.5-2643.20, and 2800-2812 Reportable Diseases and Conditions.
Demographics
What is the first and last name of the student/school staff being tested?*

First NameLast Name
Date of Birth of the person being tested:*

MonthDayYear
Date (MM/DD/YYYY)
School of attendance/employment*
Other School (Please Specify)
Is the person being tested school staff or a student?*

StaffStudent
Home street address of the person being tested (not a PO box): *
City of residence of the person being tested: *
Other City (not in Marin)*
State*
Zip Code*
Phone Number (for use in communicating with you about your COVID test): *
Please enter a valid phone number.
Email Address (for use in communicating with you about your COVID test):
example@example.com
Race of the person tested
Ethnicity of the person tested
Gender of the person being tested*
About the COVID test
Date COVID test taken*

MonthDayYear
Date (MM/DD/YYYY)
Reason for taking the COVID test (check all that apply)?

Required as part of the post-holiday return to school programI have/recently had signs or symptoms of COVID-19I have been in recent contact with someone who tested positive for COVID-19
Do you have any COVID-19 symptoms?*

YesNo
If yes, what date did your symptoms start?*

MonthDayYear
Date (MM/DD/YYYY)
What is the brand of test you used?*

iHealthBinaxNow
Test Result: (Note: If you are reporting a POSITIVE result, please also notify your school directly)*

PositiveNegativeUnsure/Indeterminate
OPTIONAL: You can help us better understand where and how Marin residents are infected with COVID 19, to guide our prevention strategies. People sometimes know or have a sense of where infection occurred. Briefly, what is your best guess on how you or/your child were infected with COVID?
Is the person being tested vaccinated for COVID-19?

Yes, fully vaccinatedYes, fully vaccinated and got a booster doseYes, but not fully vaccinated (only one dose)No, I have not/my child has not received a COVID-19 vaccine
If positive, please contact your medical provider and your school for guidance and support. You may be asked to re-test.

OPTIONAL: We want to better understand which activities were associated with an increased risk of COVID for people in Marin. How often over the holiday break did the student/school staff do the following?

	I didn't do this over the break	1-2 times	3-4 times	5 or more times
Participated in indoor sports (gym, basketball, volleyball, etc)
Other indoor activities with 10 or more people not in your household (such as parties, worship services, concerts, movies, day camps)
Traveled outside of California
Had indoor contact for an hour or more with travelers from outside the area
Spent time with others outside your household indoors while not wearing a mask

Privacy Statement: We may collect personally identifiable information as required either by law or in order for us to provide a requested service. We have privacy and security measures in place to safeguard personally identifiable information.
Should be Empty:

Post-Holiday Return to School Home Rapid Antigen Test Reporting

Demographics

About the COVID test