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
City
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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