Request for COVID19 Home Test

This limited supply of COVID-19 tests are for local (Port Angeles-Sequim) LEKT community members with symptoms or exposure to someone who's recently tested positive for COVID-19. These tests are NOT for testing prior to gatherings, travel, or leisure activities. Please complete the entire form for all household members who are requesting a test. You must have recently been exposed to someone that tested positive and/or has active covid19 symptoms. COVID-19 symptoms include: • Cough • Shortness of Breath • Fever • Chills • Fatigue • Headache • New Loss of Taste or Smell • Muscle/Body Aches • Sore Throat • Runny Nose • Congestion • Nausea • Vomiting • Diarrhea

Symptoms/Exposure*

I understand that these tests are only available for LEKT community members that are

Currently experiencing COVID symptoms or
Have recent exposure to someone who has tested positive.

Todays date*

First Name*

Last Name*

Adress*

City*

State*

Phone Number*

What is your association to the LEKT community?*

Select

Number of people in the household that are requesting a COVID-19 home test*

Select

Name of person 1 needing to test*

full name and age

Person 1: Were you/they exposed to a person COVID positive?*

Exposure: closer than 6ft for 15 or more minutes unmasked, to someone who RECENTLY tested positive for COVID 19. Exposure includes the 2 days before the COVID positive person symptoms started (or positive test if they don't have symptoms) and up to current if they have been positive for less than 10 days.

Select

Person 1: When were you/they last exposed to someone who's tested positibe for COVID19?*

Person 1: Do you/they have any active Covid-19 symptoms?*

select all that apply

Select

Person 1 tested?*

Has person 1 already been tested for these symptoms in past 2 days or currently scheduled for a test?

Select

Name of person 2 needing to test*

full name and age

Person 2: Were they exposed to a person covid positive?*

Select

Person 2: Date of last exposure to COVID positive person? 2*

Person 2: Do they have any active Covid-19 Symptoms?*

Select

Person 2 tested*

Has person 2 already been tested for these symptoms in the past 2 days or currently scheduled for a test?

Select

Name of person 3 needing to test*

full name and age

Person 3: Were they exposed to a person covid positive?*

Select

Person 3: Date of last exposure to COVID positive person?*

Person 3: Do they have any active Covid-19 Symptoms?*

select all that apply

Select

Person 3 tested*

Has person 3 already been tested for these symptoms in the past 2 days or currently scheduled for a test?

Select

Name of person 4 needing to test*

full name and age

Person 4: Were they exposed to a person covid positive?*

Select

Person 4: Date of last exposure to COVID positive person?*

Person 4: Do they have any active Covid-19 Symptoms?*

select all that apply

Select

Person 4 tested*

Has person 4 already been tested for these symptoms in the past 2 days or currently scheduled for a test?

Select

Name of person 5 needing to test*

full name and age

Person 5: Were they exposed to a person covid positive?*

Select

Person 5: Date of last exposure to COVID positive person?*

Person 5: Do they have any active Covid-19 Symptoms?*

select all that apply

Select

Person 5 tested*

Has person 5 already been tested for these symptoms in the past 2 days or currently scheduled for a test?

Select

Name of person 6 needing to test*

full name and age

Person 6: Were they exposed to a person covid positive?*

Select

Person 6: Date of last exposure to COVID positive person?*

Person 6: Do they have any active Covid-19 Symptoms?*

select all that apply

Select

Person 6 tested*

Has person 6 already been tested for these symptoms in the past 2 days or currently scheduled for a test?

Select

Name of person 7 needing to test*

full name and age

Person 7: Were they exposed to a person covid positive?*

Select

Person 7: Date of last exposure to COVID positive person?*

Person 7: Do they have any active Covid-19 Symptoms?*

select all that apply

Select

Person 7 tested*

Has person 7 already been tested for these symptoms in the past 2 days or currently scheduled for a test?

Select

Name of person 8 needing to test*

full name and age

Person 8: Were they exposed to a person covid positive?*

Select

Person 8: Date of last exposure to COVID positive person?*

Person 8: Do they have any active Covid-19 Symptoms?*

select all that apply

Select

Person 8 tested*

Has person 8 already been tested for these symptoms in the past 2 days or currently scheduled for a test?

Select

Name of person 9 needing to test*

full name and age

Person 9: Were they exposed to a person covid positive?*

Select

Person 9: Date of last exposure to COVID positive person?

Person 9: Do they have any active Covid-19 Symptoms?*

select all that apply

Person 9 tested*

Has person 8 already been tested for these symptoms in the past 2 days or currently scheduled for a test?

Select

Name of person 10 needing to test*

full name and age

Person 10: Were they exposed to a person covid positive?*

Select

Person 10: Date of last exposure to COVID positive person?*

Person 10: Do they have any active Covid-19 Symptoms?*

select all that apply

Select

Person 10 tested*

Has person 10 already been tested for these symptoms in the past 2 days or currently scheduled for a test?

Select

How would you like to recieve the COVID-19 tests?*

Select

Attestation*

I attest that I am the individual listed above, and have provided truthful answers to the questions. I further understand that the requested COVID tests are to be use for individuals in local (Port Angeles/Sequim) LEKT homes. If falsealifying of information or misuse of COVID tests are identified, I may be charged for the cost of the test and administrative time associated with delivery.

Send me a copy of my responses

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