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2. Last Name
3. First Name
5. City of Residency
6. Date of Positive Test Result*
   Date of Positive Test Result
7. Age
8. Gender

   1. Male
   2. Female
   3. Prefer not to answer
10. My test result was:

    1. Positive - Please fill out the rest of this form.
    2. Negative - You can stop and submit the form now.
12. Did you receive a COVID-19 Vaccine?

    1. Yes
    2. No
13. If yes, please check the box most accurate

    1. I have received a booster dose of a vaccine.
    2. I have completed the primary series ofPfizer or Moderna vaccines within the last 5 months.
    3. I have completed the primary series of J&J vaccine within the last 2 months.
    4. I have completed the primary series ofPfizer or Moderna vaccines more than 5 months ago.
    5. I have completed the primary series of J&J vaccine more than 2 months.
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15. 1. Receive an email copy of this form.
16. Email address

    This field is not part of the form submission.

17. Submit

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