Staff COVID Notification

NEOCAP COVID HOME TEST REPORTING FORM

This record acknowledges that you have tested positive for COVID 19 using a Home Testing Kit and that you must isolate for 5 days. This record will be filed with Trumbull County Combined Health District who will follow up with you regarding your results. The following information is required.

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

Name of Home Test Used: *

Date of Home Test: *

Results: *

Positive Negative

Comment *

Submit