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BinaxNow Rapid Antigen Card

2. First Name*

3. Last Name*

4. Date of Birth*

6. Address*

8. City*

9. Zip Code*

11. Homeless*

    1. Yes
    2. No

12. Phone Number*

13. Email Address*

15. Date of Test*

16. Result*

    1. Positive
    2. Negative

17. Any Symptoms?*

    1. Yes
    2. No

    (eg, runny nose, cough, fever, loss of taste and smell, fatigue, headache, chills, difficulty breathing, etc)?

19. Any close contact exposure to a COVID-19 case in the last 14 days?*

    1. Yes
    2. No

20. Employer*

    1. Hospital or Healthcare
    2. SNF
    3. ALF, RCFE, or Memory Care
    4. EMS
    5. Fire
    6. Law or Corrections
    7. School or Daycare
    8. Other

21. Employer Description*

23. Name of Workplace*

25. Workplace Address*

27. City*

28. Zip Code*

30. Workplace Point of Contact Name*

31. Workplace Point of Contact Number*

Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

* indicates a required field