Unlock hundreds more features
Save your Form to the Dashboard
View and Export Results
Use AI to Create Forms and Analyse Results

Forgot Password?
Get Started
OR
Sign UpLogin With Facebook
Sign UpLogin With Google

COVID 19 Positive Diagnosis Form Template

Streamline Your Reporting with a COVID-19 Diagnosis Form

Dealing with a positive COVID-19 diagnosis can be overwhelming, especially when it comes to proper reporting. This template is designed for businesses needing to efficiently collect and manage information about employees who test positive for COVID-19. With features like automatic data organization, customizable fields, and easy sharing options, you can swiftly track and respond to health needs while ensuring compliance. Plus, our compliant design aligns with accessibility standards to serve all your employees. Explore the live template to simplify your workflow.

Use this Template (FREE) Live Preview
Full name
Email address
Phone number
Organization or school
Was your most recent COVID-19 test positive?
Yes
No
Date of positive test
Type of COVID-19 test
PCR or lab NAAT
Rapid antigen (supervised)
Rapid antigen (self-administered)
Other or not sure
Are you currently experiencing symptoms?
Yes
No
Date symptoms began (if any)
Most recent day you were on-site/in person (if applicable)
Symptoms experienced (select all that apply)
COVID-19 vaccination status
Up to date with recommended doses
Partially vaccinated
Not vaccinated
Prefer not to say
Do you have any high-risk conditions?
Are you able to isolate at home away from others?
Yes
No
I authorize the organization to use this information for public health and safety purposes.
Yes
No
Full name as signature
Date signed
I certify the information provided is accurate to the best of my knowledge.
Yes
No
{"name":"Full name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Full name, Email address, Phone number","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}

When to use this form

This template helps you document a lab-confirmed case so you can notify HR, school, or care teams fast. Use it when an employee, student, or patient needs clear, consistent details for leave, isolation, or benefits. Capture test type and date, symptoms, and isolation timelines in one place, then export or share as needed. Employers can coordinate a return date alongside the Urgent care work release form. If you have upcoming travel or border requirements, include a status declaration using the Public health travel declaration form. Clinics and admins also benefit from standardized data that reduces back-and-forth and speeds decisions.

Must Ask COVID 19 Positive Diagnosis Questions

  1. What was your test date and test type (PCR/NAAT or antigen)?

    This pins down the infectious window and supports policies that treat PCR and antigen results differently. It also lets admins verify documentation using the Medical record audit form.

  2. When did your symptoms start, and what symptoms are you experiencing?

    Symptom onset refines the exposure period and helps decide when to end isolation. Listing symptoms guides triage and follow-up.

  3. Have you been fever-free for 24 hours without medicine, and are your symptoms improving?

    This determines readiness to return to work or class safely. It lowers transmission risk and sets a clear, defensible return date.

  4. What isolation dates are you following, and whose guidance (employer, school, or local health) are you using?

    Stated dates align your plan with policy and help schedulers plan coverage. Citing the source prevents confusion and speeds approvals.

  5. Were you treated in a hospital or urgent care, and what were your discharge instructions?

    Hospital or urgent care care often adds specific restrictions and follow-up steps. If admitted, attach your Hospital discharge form to confirm dates and instructions.

More Forms

Copy/Edit Form Send to Recipients Make a Form w/AI Form Builder Must Ask Questions
  • 100% Free - No Catches
  • Collect Responses Today
  • Tailor to your Look & Feel