Health Reporting Form
Are you reporting for yourself or for another individual? *
Is the individual currently hospitalized? *

Information About Sick Individual

Affiliation *
Residence
Have you had contact with other persons positive for COVID-19? *
Do you live in a region with widespread COVID-19? *
Tested for COVID-19? *
Did you test positive for COVID-19?
Have you been tested for Flu? *
Were you diagnosed with Flu?
Have you been instructed by a medical professional to self-quarantine due to symptoms? *
Have you been instructed by to self-quarantine due to exposures? *
What symptoms have you had so far? (Check all that apply)
Contact is defined as being within six feet of someone for 15 minutes or more during a 24 hour period.
Contact is defined as being within six feet of someone for 15 minutes or more during a 24 hour period.
Do you consent to us sharing your de-identified information for the purpose of community illness/risk tracking among the Goucher community?
You must check Yes to submit this form.
Do you consent to us sharing your COVID+ diagnosis and contact information with the Baltimore County Health Department? Goucher is required to share this information with the Health Department and all information will be sent in a HIPAA-protected manner.
You must check Yes to submit this form.