Today Y-M-D
Dag ID:
* must provide value
* must provide value
Date of BirthFecha de nacimiento
* must provide value
M-D-Y
patient age View equation
Date of birth is in the future. Please add a valid date of birth.
Student ID:
* must provide value
Female (Mujer)
Male (Hombre)
Not Provided (No proporcionado)
Female (Mujer)
Male (Hombre)
Not Provided (No proporcionado)
Please fill out the parent/guardian information Guardian First Name
Guardian Last Name
Guardian DOB
M-D-Y
Guardian Phone
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Hispanic or Latino (Hispano o latino) NOT Hispanic or Latino(NO Hispano o Latino) Unknown (Desconocido) Not Reported (No Reportado) Hispanic or Latino (Hispano o latino)
NOT Hispanic or Latino(NO Hispano o Latino)
Unknown (Desconocido)
Not Reported (No Reportado)
* must provide value
Asian Black or African American Native Hawaiian or Other Pacific Islander American Indian or Alaska Native White Other Race Unknown / Not Reported Asian
Black or African American
Native Hawaiian or Other Pacific Islander
American Indian or Alaska Native
White
Other Race
Unknown / Not Reported
* must provide value
* must provide value
* must provide value
Utah 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 Vermont Virginia Washington West Virginia Wisconsin Wyoming
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Phone numberNumero de teléfono
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Include Area Code
Please provide the email where you would like test results sent. The email provided will be used to send a secure email containing results from the test.
Por favor, proporcione el email donde quiere que se le envíen los resultados de la prueba. El email proporcionado será usado para enviar un email seguro con los resultados de la prueba.
* must provide value
Confirm Email Address:Confirme la dirección de e-mail:
* must provide value
cemail View equation
Email addresses do not match, in order to receive your test result over email you must confirm your email address.
Individual Type Patient/Resident
Healthcare Worker
Staff Member
Visitor
Patient/Resident
Healthcare Worker
Staff Member
Visitor
Exposure risk category - Healthcare Worker/Staff
Use the picture below to help determine risk. Please ask your facility administrator to help you determine your risk level if uncertain.
Exposure risk category
Use the picture below to help determine risk. Please ask your facility administrator to help you determine your risk level if uncertain.
Exposure Risk Low
Higher
No known risk
Are you pregnant? Yes (Si)
No
Is this the first time you have been tested for COVID-19?¿Es esta la primera vez que se hace la prueba de COVID-19?
* must provide value
Yes (Si)
No
Unknown (Desconocido)
Yes (Si)
No
Unknown (Desconocido)
Are you employed in healthcare?¿Trabaja en el cuiado de la salud?
* must provide value
Yes (Si)
No
Do you have any of the following symptoms?
¿Tiene alguno de los siguientes síntomas?
Fever or chills (Fiebre o escalofríos), cough (Tos), shortness of breath or difficulty breathing (Falta de aliento o dificultad para respirar), fatigue (Fatiga), muscle or body aches (Dolores musculares o corporales), headache (Dolor de cabeza), new loss of taste or smell (Nueva pérdida de gusto u olor), sore throat (Dolor de garganta), congestion or runny nose (Congestión o secreción nasal), nausea or vomiting (Náuseas o vómitos, diarrea), diarrhea
* must provide value
Yes (Si)
No
Unknown (Desconocido)
Yes (Si)
No
Unknown (Desconocido)
Were you hospitalized because of COVID-19?¿Ha sido hospitalizado por COVID-19?
* must provide value
Yes (Si)
No
Were you admitted to the ICU because of COVID-19?¿Estuvo internado en una unidad de cuidados intensivos por COVID-19?
* must provide value
Yes (Si)
No
Are you a resident in a congregate care setting?(including nursing home, residential care for people with intellectual and developmental disabilities, psychiatric treatment facility, group home, board and care home, homeless resource center, foster care or other setting)
¿Es usted residente en un centro de cuidados colectivos?
(incluyendo un hogar de ancianos, atención residencial para personas con discapacidades intelectuales y de desarrollo, centro de tratamiento psiquiátrico, hogar grupal, hogar de hospedaje y cuidado, centro de recursos para personas sin hogar, cuidado adoptivo u otro ambiente)
* must provide value
Yes (Si)
No
I consent to receive my COVID-19 test result through a secure email. If I do not consent, I can receive a paper result at the testing location.Doy mi consentimiento para recibir el resultado de mi prueba de COVID-19 a través de un correo electrónico seguro. Si no doy mi consentimiento, puedo recibir el resultado en papel en el lugar de la prueba.
I Consent (Doy mi consentimiento)
I DO NOT Consent (NO doy CONSIENTO)
I Consent (Doy mi consentimiento)
I DO NOT Consent (NO doy CONSIENTO)
*** Your email address is not confirmed. If you would like to receive your test result over email, please verify your email address is correct and and confirmed.
Please read carefully:Utah Code Annotated 53E-9-305(6) requires schools to notify parents of any biometric collections of student information. This information will only be collected after the school obtains written consent from the parent or from a student who has turned 18. Biometric identifier to be collected: The rapid antigen test, which constitutes a human biological sample used for valid scientific testing or screening. Purpose of collection: This program is an effort to support continued high school sports and extracurricular activities while maintaining efforts to interrupt the transmission of COVID-19 in the school environment. How the biometric identifier will be used and stored: The actual sample will be destroyed as biohazard waste. Results of the testing will be entered into the state’s Redcap system and accessible to school staff only for providing legitimate educational services.
Notice of Disclosure of Education Records The Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. § 1232g; 34 CFR Part 99) generally requires that schools notify parents before a disclosure of information from student education records. As a parent or student who has turned 18, you have a right to request a copy of your records that have been disclosed to the Utah Department of Health. Records to be disclosed: Test results that have been entered into the Redcap system Recipient: Utah Department of Health Purpose: F or the department to fulfill its surveillance requirements under Utah Administrative Rule R386-702 for communicable disease reporting
Consent Parents, guardians, or eligible student (over 18 years old) have the right to revoke this consent and authorization at any time. I have read the above and consent to have my student tested for COVID 19 and grant express authorization for the State Health Department to access my child’s test results
* must provide value
I consent (for myself) I consent for my minor child I don't consent I consent (for myself)
I consent for my minor child
I don't consent