COVID-19 Response Web App

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What Type of Concern
Symptoms
Pre-Existing Conditions
Have you tested positive?
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 access to resources (food, water, medications, help)?
Do you have behavioral health support?
Do you think you may have had the COVID-19 virus and have now recovered?
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
Age
Gender
Blood Type
Code
Area Code
Phone
Type
Do you have SSN Information? ?

Do you have Driver’s License?

Are You Insured?

Email
Additional Comments (Optional)
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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