UC System ID
Date pre-registration started Today M-D-Y
First Name* must provide value
Middle Name
Last Name* must provide value
Date of Birth* must provide value
M-D-Y Example: 02-29-1985
NAME and DATE OF BIRTH are REQUIRED For all other information please complete as best you can, leave blank if information is unavailable
Phone Number (no dashes) Example: 5131112222
Phone Type Home/House
Cell
Work
Other
Alternate Phone Number (no dashes) Example: 5131112222
Alternate Phone Type Home/House
Cell
Work
Other
Email where your results will be sent
Street Address
Apt/Unit Num
City
State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
County Adams Boone Brown Butler Campbell Clark Clermont Dearborn Franklin Grant Hamilton Harrison Jefferson Kenton Perry Ripley Scott Union Warren Other
Other county (specify):
Zip Code
Test results can be provided to (check all that apply):* must provide value
Person getting tested
Parent/Guardian
Other
Other (specify, for example "assisted living manager", or "daughter"):
Use this information (entered above) if we need to contact you about your test? (If you are a parent/legal guardian for this person, please check "no" to enter your contact information) Yes
No
alt_contact_calc View equation
Please enter contact information for parent/guardian/other:
Contact information for result notification
Relationship to person being tested today: Friend Family Employer Other
Other (please specify)
Relationship to person being tested today: Parent/Guardian Other
First name
Last name
Email
Phone Number (no dashes): Example: 5131112222
Phone Type Home/House
Cell
Work
Other
Alternate Phone Number (no dashes): Example: 5131112222
Alternate Phone type Home/House
Cell
Work
Other
Use same address? Yes
No
Street Address
Apt/Unit Num
City
State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
County Adams Boone Brown Butler Campbell Clark Clermont Dearborn Franklin Grant Hamilton Harrison Jefferson Kenton Perry Ripley Scott Union Warren Other
Is there another contact person for receiving test results? Yes
No
Relationship to person being tested today: Friend Family Employer Other
Other (please specify)
Relationship to person being tested today: Parent/Guardian Other
First name
Last name
Email
Phone Number (no dashes): Example: 5131112222
Phone Type Home/House
Cell
Work
Other
Alternate Phone Number (no dashes): Example: 5131112222
Alternate Phone type Home/House
Cell
Work
Other
Use same address? Yes
No
Street Address
Apt/Unit Num
City
State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
County Adams Boone Brown Butler Campbell Clark Clermont Dearborn Franklin Grant Hamilton Harrison Jefferson Kenton Perry Ripley Scott Union Warren Other
HEALTH INSURANCE Social Security Number (no dashes) Ex: 333224444
Name of Policy Holder
Policy Holder's First Name
Policy Holder's Last Name
Name of Insurance Company
Insurance Company Phone Number (No Dashes): Example: 5131112222
Group ID / MMIS#
Insurance ID / Member Number
Race (check all that apply) White
Black/African American
Asian
Native Hawaiian/Pacific Islander
American Indian/Alaskan native
Other
Prefer not to answer
Other race:
Ethnicity: Hispanic/Latino
Non-Hispanic/Latino
Male
Female
Other
Can you answer medical questions in English? Yes
No
If no, what is your preferred language? If not comfortable with English
Please check below if you have had NEW and UNEXPLAINED symptoms IN THE PAST 14 DAYS.
Fever or chills
Cough
Fatigue
Nausea or vomiting
Muscle or body aches
Headache
New loss of taste or smell
Diarrhea
Shortness of breath or difficulty breathing
Sore throat
Congestion or runny nose
None of these
symptomatic_calc View equation
If you had any symptoms, about how many days ago did you first have symptoms: Number of Days
If yes, about how many days ago did you first have contact? Number of Days
Have you EVER been diagnosed with COVID? Please check the box that applies: No
Yes, within the past week
Yes, within the past month
Yes, within the past three months
Yes, more than three months ago
When was your LAST test for COVID? Please check the box that applies: Never been tested
Within the past week
Within the past month
Within the past three months
More than three months ago
first_test_calc View equation
If you were tested before, what were the results of your LAST test? Negative
Positive
Do not know
Do you have any health conditions? Yes
No
Height (feet):
Height (inches):
Weight (pounds):
weight_kilograms View equation
height_inches View equation
height_meters View equation
View equation
If yes, do you have any additional contact information you would like to provide?
How did you hear about us? Billboard
Social Media
Ad
Friend/Family
Flyer
Other:
Other:
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