COVID-19 Response Web App

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Are you showing symptoms?
Symptoms
What is the date you started showing symptoms?
Pre-Existing Conditions
Have you come into close contact (within 6 feet) with someone who has a laboratory confirmed COVID-19 diagnosis in the past 14 days?
Do you have a fever (greater than 100.4 F or 38.0 C) OR symptoms of lower respiratory illness such as cough, shortness of breath, or difficulty breathing?
Do you have behavioral health support?
What is your Race?
What is your ethnicity?
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Your Information

First Name
Last Name
State
Main City
Actual City (Optional)
Street Address
Zip Code
Date of birth
Gender
Code
Area Code
Phone
Type
Do you have Driver’s License?

Are You Insured? ?

Email
Emergency/Guardian Contact Name
Emergency/Guardian Contact Email
Emergency/Guardian Contact Relationship
Emergency/Guardian Contact Phone
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Alert!

Please call 911 or go to the ER immediately as your symptoms require a Doctor's care and you cannot wait for a test to be scheduled

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