COVID-19 Test Screening - August 9, 2020
IMPORTANT INSTRUCTIONS FOR TESTING, PLEASE READ: Please complete the screening tool below to pre-register for testing at our drive-thru clinic at Ichabod Crane High School in Valatie on August 9, 2020. Please provide a telephone number where you can be reached at the end of this form, so that the Columbia County Department of Health (CCDOH) can contact you for further information if necessary. You will receive a confirmation email to confirm your pre-registration (this is not an automatic email; it will be sent prior to the test date). If you are symptomatic, you will be expected to quarantine until your test results are received. You will be contacted with your results by the county you reside in. Results can take up to 5-7 days to be received by the local health departments. PLEASE ALSO NOTE THAT THIS TEST WILL BE IN THE FORM OF A NASOPHARYNGEAL SWAB AND IS NOT AN ANTIBODY TEST.

Pre-registration is required for testing on this date. If you do not register ahead of time, you can not be tested at this clinic.

Please be aware that by filling out this form you are providing voluntary consent to testing.
Email address *
Are you experiencing any of the symptoms associated with the COVID-19 illness (fever, shortness of breath or difficulty breathing, sore throat, chills, new loss of taste or smell, headache, cough)? *
If you answered yes to the question above, please describe your symptoms below:
If you are experiencing symptoms, please note below the date they began.
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To your knowledge, have you been in contact with an individual who has tested positive for COVID-19? *
If you answered yes to the above question, has it been at least three days since you were exposed to the individual who tested positive?
Clear selection
Are you currently employed as a healthcare worker (nursing home, hospital, or other medical facility)? *
Are you currently active or employed as a first responder (firefighter, EMT, paramedic, law enforcement officer)? *
Do you work in Columbia County? *
Are you required to be tested as a condition of your employment? *
First Name *
Last Name *
Physical address *
Mailing address (if different from above)
Date of Birth *
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Telephone number *
(The three following questions ask for personal information that is being collected by the State Department of Health to better understand COVID-19. Answering these questions is entirely optional. Your responses will not affect the priority of your testing or the time in which you will receive your results). What is your race?
Clear selection
What is your ethnicity?
Clear selection
What is your gender?
Clear selection
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