Monroe County, NY Positive COVID-19 Home Test Reporting Form

This form is for voluntary reporting of POSITIVE home test results. The Monroe County Department of Public Health will not contact you.

Please do not use this form if:

• Your test was administered at a physician’s office, pharmacy or lab, since these tests are automatically reported to Monroe County.
• Your home test result is negative.
• You do not live in Monroe County, NY

If your employer/school requires documentation of your isolation, please use the New York State Department of Health AFFIRMATION OF ISOLATION form. This self-reporting form serves as your Order of isolation and can be submitted for New York Paid Family Leave COVID-19 claims.

• NYS Affirmation of Isolation & Quarantine Forms

* Required Fields

First Name *

Middle Name

Last Name *

Date of Birth *

Gender *

Male Female Trans Male Trans Female Non Binary Other Prefer Not To Answer Unknown

Did you test positive for COVID-19? *

Yes
No

Date of COVID-19 Test *

Your Zip Code *

By checking this box to certify the answers above, I swear or affirm that the answers I have provided above are true to the best of my knowledge. I understand that if I have knowingly made a false statement herein, I may be subject to prosecution under New York Penal Law § 210.45. I certify this is true.

Submit Form