COVID Self Reporting Form

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Herkimer County residents can report positive results from COVID-19 self-tests (also known as at-home or over the counter COVID-19 tests)

Herkimer Count residents can use this form to tell Herkimer County Public Health (HCPH) about a positive COVID-19 self-test result. The self-test must be authorized by the Food and Drug Administration (FDA). A list of authorized self-tests can be found by searching the term ‘OTC” on the FDA website.

Negative results from self-tests do NOT need to be reported. Self-tests can NOT be used for release from quarantine.

The form should NOT be used to report results of a test obtained or performed at or through a doctor’s office, clinic, hospital, laboratory, pharmacy, school, or any testing site or program operated by HCPH.

If additional information is needed, Herkimer County Public Health will contact you.

*Brand Type of Test:

*Date of Positive Test:

*Does the person with the positive self-test currently have any COVID-19 symptoms?

*Who can we contact to get more information about the person with the positive self-test?

*First Name:

*Last Name:

*Birth Date of Person with Positive Test:

Primary Phone #:

Secondary Phone #:

*Street Address:

*City:

*ZIP Code:

*Specimen Collection Date:

Test Analysis Date:

Survey

Does the person with the positive self-test live, work, visit, or provide services to people at congregate living facilities?

Does the person with the positive self-test attend or work at a K-12 school?

Does the person with the positive self-test attend or work at a Pre-K or Daycare (Licensed or Not Licensed)?

Does the person with the positive self-test work for a village, town, city, county, state or federal government agency other than law enforcement?

Does the person with the positive self-test work for a law enforcement or first responder agency?

BY CHECKING 'YES' ON THIS BOX YOU ARE SWEARING TO THE VERACITY OF THE INFORMATION YOU HAVE PROVIDED ON THE FORM, ACKNOWLEDGE THAT HCPHS MAY VERIFY THE INFORMATION YOU HAVE PROVIDED, AND MAY CONTACT YOU FOR ADDITIONAL INFORMATION. *

Affirmation:

Privacy Disclosure:

Herkimer County Public Health Services (HCPH) is strongly committed to protecting personal information collected through this website against unauthorized access, use or disclosure. Consequently, HCPH limits employee access to personal information collected through this website to only those employees who need access to the information in the performance of their official duties. Employees who have access to this information follow appropriate procedures in connection with any disclosures of personal information. In addition, HCPH has implemented procedures to safeguard the integrity of its information technology assets, including, but not limited to, authentication, monitoring, auditing, and encryption. These security procedures have been integrated into the design, implementation, and day-to-day operations of this website as part of our continuing commitment to the security of electronic content as well as the electronic transmission of information.

HCPH may collect or disclose personal information without consent if the collection or disclosure is: (1) necessary to perform the statutory duties of the HCPH, or necessary for HCPH to operate a program authorized by law, or authorized by state or federal statute or regulation; (2) made pursuant to a court order or by law; (3) for the purpose of validating the identity of the user; or (4) of information to be used solely for statistical purposes that is in a form that cannot be used to identify any particular person.

COVID Self Reporting Form

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