UC System ID
Date pre-registration started Today M-D-Y
Date pre-registration started Now M-D-Y H:M
This is a UC Student that has successfully registered through the UC registration link 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
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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
Insurance Plan: AARP MEDICARE SUPPLEMENT AETNA AETNA MEDICARE ADVANTAGE AETNA POS ALL SAVERS ALLIED BENEFITS SYSTEM INC. ALLWELL BY BUCKEYE MEDICARE ADVANTAGE AMBETTER ANTHEM BCBS OF OHIO BCBS APWU - AMERICAN POSTAL WORKERS UNION BLUE CROSS BLUE SHIELD OF KENTUCKY FEP BCBS BUCKEYE HEALTH PLAN - OH MCO CAREFIRST BLUECHOICE CARESOURCE - OH MCO CARESOURCE JUST 4 ME OH CHRISTIAN BROTHERS EMPLOYEE BENEFIT CIGNA CUSTOM DESIGN BENEFITS EBMS/HEART OF THE ROCKIES GEHAFEHB GOVERNMENT EMPLOYEES HEALTH ASSOCIATES GREAT WEST HEALTHCARE/CIGNA (GWH) HUMANA GOLD HUMANA INC. MCR HUMANA ADVANTAGE PLAN MCR MOLINA OHIO ADVANTAGE PLAN MEDBEN MEDICA COMMERCIAL MEDICAID OHIO MEDICAL MUTUAL OF OHIO/SUPERMED Medicare Part B MERITAIN HEALTH MOLINA HEALTHCARE - OH MCO MUTUAL HEALTH SERVICES PARAMOUNT ADVANTAGE - OH MCO PARAMOUNT INSURANCE COMPANY TRICARE EAST Tricare West Region TRUSTMARK UMR (UNITED MEDICAL RESOURCES) UNITED HEALTHCARE (UHC) - MEDICARE UNITED HEALTHCARE CHOICE PLUS UNITED HEALTHCARE COMMUNITY PLAN - OH MCO UNITED HEALTHCARE INTEGRATED/SHARED SERVICES - GEHA UNITED HEALTHCARE STUDENT RESOURCES UNITED HEALTHCARE-740803 UNITED HEALTHCARE-GOLDEN RULE UNITED MEDICAL RESOURCES (UMR) UHC SHARED SERVICES WELLCARE WESTERN SOUTHERN FINANCIAL GROUP Other insurance plan
Other Insurance Plan:
Note: If you have the UC Student Health Insurance Plan (SHIP), this uses the UnitedHealth Care Physician network (Student Resources).
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
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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
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If you were tested before, what were the results of your LAST test? Negative
Positive
Do not know
Have you ever been hospitalized for COVID19? Yes
No
If yes, were you in the ICU (Intensive Care Unit)? Yes
No
Are you a resident in a congregate care setting?including nursing homes, residential care for people with intellectual and developmental disabilities, psychiatric treatment facilities, group homes, board and care homes, homeless shelter, foster care, or other setting
Yes
No
Have you received a COVID19 vaccination? Yes No
Date of First Shot:
Today M-D-Y
Brand of Vaccine:
J&J Moderna Pfizer Other
Other Brand of Vaccine:
Date of Second Shot:
Today M-D-Y
Brand of Vaccine:
J&J Moderna Pfizer Other
Other Brand of Vaccine:
Date of Booster Shot:
Today M-D-Y
Brand of Booster:
J&J Moderna Pfizer Other
Other Brand of Vaccine:
Do you have any health conditions? Yes
No
Height (feet):
Height (inches):
Weight (pounds):
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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:
Have you been fully vaccinated for COVID19? Yes No Unsure
Will you be using your results for upcoming travel? Yes No Unsure
Test and Protect will cease testing on December 28, 2021 , and conclude operations by the end of the year. Visit testandprotectcincy.com for a listing of no-cost testing options.
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