Denton County Public Health | COVID-19 Self-Test Reporting

Self-Test Reporting Questions
You are not eligible to complete this form.
This form is for Denton County, TX residents ONLY.
This form is for Positive Self-Test Only.
This form is for reporting on behalf of the individual themselves or the parent/guardian of a minor child.
Do you reside in Denton County?
Did you test positive for COVID-19 using an at-home performed test?
Are you reporting a positive test for yourself or are you a parent/guardian reporting a positive test for your child?

Demographic Information

Name of individual with positive test:
First Name
Last Name
Date of Birth

MonthDayYear
Gender
Parent/Guardian Name (If Applicable)

First NameLast Name
Residential Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address

Confirmation Emailexample@example.com
Enter numbers only. No dashes, spaces, or parentheses. The number must be exactly 10 digits.
By providing your phone number you consent to receive phone calls and voice messages from DCPH.
Mobile Phone
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Other Phone
Please enter a valid phone number.Format: (000) 000-0000.

Case Data
Please provide the following demographic information. Sex, Race, and Ethnicity are not required for determining eligibility however are required for our reporting of vaccine doses administered.
Did you have contact with a confirmed case prior to testing positive?
Did you travel in the 14 days prior to developing symptoms or testing positive?

Activities
Did you do any of the following activities below in the 2 days before getting sick or while sick?
- Go to work, school, or attend childcare?
- Attend any large gatherings?
- Participate in any sporting activities?
- Obtain medical care, mental healthcare, or dental care?
Please identify each location you visited or attended. If available, provide name, address, and date last visited.

Vaccination
"First Dose Date" cannot occur after "Second Dose Date". Please select correct the dosage dates.
"Second Dose Date" cannot occur after your "Third/Booster Dose Date". Please select correct the dosage dates.
"Third/Booster Dose" cannot occur before your "First Dosage Date". Please select correct the dosage dates.
"Third/Booster Dose Date" cannot occur before your "Second Dosage Date". Please select correct the dosage dates.
Have you been vaccinated against COVID-19?
First dose manufacturer
First dose date

MonthDayYear
Second dose manufacturer
Second dose date

MonthDayYear
Third/booster dose manufacturer
Third/booster dose date

MonthDayYear
Please verify that you are human
Should be Empty:

COVID-19 SELF-TEST REPORTING