COVID-19 Testing and Tracing Inquiry Form

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone Number*

Email*

Please select all that apply. I prefer to be contacted by:

If you are more comfortable using a language other than English, please indicate the language(s) here.

If you need an accommodation like large print, braille, ASL, or other, please indicate that here.

Would you like information and/or resources about COVID-19?*

Yes
No

Would you like COVID-19 testing site information and/or resources?*

Yes
No

Would you like someone to get back to you with more information and/or resources?*

Yes
No

Have you been tested for COVID-19?*

Yes
No
Not sure
I prefer not to answer and/or disclose this information.

Do you want to get tested for COVID-19?*

Yes
No
Not sure
I prefer not to answer and/or disclose this information.

If you want to get tested for COVID-19 and/or you got tested, what has/have been your experience(s)? Please let us know of any issues, concerns, and/or problems that you had/have.

Do you have any questions, feedback, concerns, and/or issues relating to testing and tracing for and/or during COVID-19? Please indicate that here.

Is there anything else you would like to ask or share? Please indicate that here.