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COVID-19 Test Result Reporting Form Template

Effortlessly collect and report COVID-19 test results

Managing COVID-19 test results can be overwhelming, especially when adhering to health guidelines. This template helps organizations like yours efficiently gather and submit positive test results from employees, students, or clients. You'll benefit from a user-friendly design that supports file uploads, is customizable to your needs, ensures secure data collection, and is accessible on any device. Take a moment to explore the live template and see its features in action.

Use this Template (FREE) Live Preview
Full name
Date of birth
Email address
Phone number
ZIP or postal code
Country
What type of COVID-19 test did you take?
Rapid antigen (at-home or point-of-care)
PCR or NAAT
Other or not sure
Test brand or manufacturer (optional)
Date you took the test
What was your test result?
Positive
Negative
Invalid/No result
Inconclusive/Indeterminate
Unknown
What was the main reason for testing? (select all that apply)
Symptoms
Contact or exposure
Routine screening
Travel requirement
Work or school requirement
Medical or pre-procedure
Prefer not to say
Other
Please Specify:
Have you had any COVID-19 symptoms in the last 14 days?
Yes
No
Which symptoms have you had? (select all that apply)
If you had symptoms, when did they start? (optional)
In the last 14 days, have you been in close contact with someone who tested positive for COVID-19?
Yes
No
Have you received any COVID-19 vaccine dose(s)?
Yes, at least one dose
No, not vaccinated
Prefer not to say
What is your age group?
Under 18
18-24
25-34
35-44
45-54
55-64
65+
Gender identity
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
I consent to share this report with public health authorities to support COVID-19 monitoring and response.
Yes
No
Type your full name as signature
Date of signature
I certify the information provided is accurate to the best of my knowledge.
Yes
No
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When to use this form

Use this template to collect and document test outcomes from patients, staff, students, or visitors in one place. It works when you need to verify a home rapid result, log a clinic PCR, or capture proof for HR or school clearance. Small practices can speed intake and reduce phone tags, while larger teams get clean data for follow-up and reporting. Pair it with a Laboratory requisition form when a confirmatory test is required. If you screen people before entry, add a Health declaration form for pre-visit risk checks. After results are recorded, share clear next steps using a Discharge instructions form.

Must Ask COVID-19 Test Result Reporting Questions

  1. What is your full name, date of birth, and the best way to reach you?

    Identity details prevent mix-ups and let you match results to the right person. Reliable contact info ensures you can deliver guidance or follow up quickly if action is needed.

  2. When did you take the test (date and time)?

    The timestamp anchors isolation windows and return-to-work or school decisions. It also helps link results to exposure and symptom timelines for clearer risk assessment.

  3. Which type of test did you take and where (PCR/NAAT or rapid antigen; home, clinic, or lab)?

    Test type and setting affect accuracy and next steps, such as whether a confirmatory lab test is advisable. Location details also guide reporting and resource planning.

  4. What was the result (positive, negative, or inconclusive), and can you provide proof (photo, code, or report number)?

    Stating the outcome with basic verification reduces errors and speeds decisions. You can standardize next steps by sending a Discharge instructions form tailored to the result.

  5. Do you have COVID-19 symptoms, and when did they start? Any red-flag signs (trouble breathing, chest pain)?

    Symptom details refine isolation guidance and help you prioritize high-risk cases. If severe symptoms are reported, prompt an urgent pathway with a Hospital admission form.

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