Test results – Azure Biotech Inc.

All fields marked with * are required and must be filled.
Use this form to report results from taking an at home COVID-19 test, also known as an over the counter test or self test. Your response is confidential, and reporting your test result helps the Health Department understand how many Vermonters are being tested for COVID-19 and how the virus is spreading in our communities.

What was the reason for taking this COVID test?

Name of the person being tested: *

Date of Birth of the person being tested: *

Gender of the person being tested: *

Race of the person being tested:

Ethnicity of the person being tested:

Email Address for use in communicating with you about your COVID test: *

Phone Number for use in communicating with you about your COVID test: *

Are you unstably housed and/or experiencing homelessness? *

Yes No

Do you need assistance/guidance with isolation?

Yes No

Date the test was taken: *

Test Result: (Note: If you are reporting a positive result, Marin Public Health recommends you also notify your Primary Care Provider) *

Positive Negative Unsure

OPTIONAL: You can help us better understand where and how Marin residents are infected with COVID 19, to guide our prevention strategies. People sometimes know or have a sense of where infection occurred. Briefly, what is your best guess on how you or/your child were infected with COVID?

Is the person being tested vaccinated for COVID-19?

Yes, fully vaccinated Yes, fully vaccinated and got a booster dose Yes, but not fully vaccinated (only one dose) No, I have not/my child has not received a COVID-19 vaccine

Did the person being tested have any symptoms? *

Yes No

What is the usual occupation of the individual being tested? *

Does the individual being tested attend, or work at a school, childcare, or other youth programs (such as after-school care or youth sports)? *

Yes No

Does the individual taking the test work at a residential facility or other congregate or group living setting? *

Yes No

Please note: This test may not count for employers or travel. You may need additional lab testing depending on the requirements of your employer or travel airline or destination. Public Health will require follow-up PCR testing if you are requesting a clearance letter.

We do not recommend that you get an additional PCR test to confirm your positive rapid home antigen result.
A positive COVID-19 test result requires that you notify your employer immediately - please notify your employer and any schools or programs you have attended in person in the last week.

Privacy Statement: We may collect personally identifiable information as required either by law or in order for us to provide a requested service. We have privacy and security measures in place to safeguard personally identifiable information.