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2. If you are a Brookline resident and have tested positive for COVID-19 using a home test kit (e.g., BinaxNOW, iHealth), please submit the following form to the Brookline Public Health Department. The Town of Brookline respects your right to privacy and confidentiality. By filling out this form you are consenting to the collection, processing, and use of the information you provide.

4. What date did you test positive for COVID-19 using an at-home test?*
   What date did you test positive for COVID-19 using an at-home test?
5. If you have symptoms related to COVID-19 on what date did they begin?
   If you have symptoms related to COVID-19 on what date did they begin?
7. Why did you test yourself for COVID-19?*
   -- Select One --I have symptoms of COVID-19I am a close contact of someone who tested positive for COVID-19I plan to visit someone who is at high-risk of serious illnessRequired for work, school, or travelOther
8. What is the name of the self-test that you used? *
   -- Select One --Abbott’s BinaxNOW COVID-19 Antigen Self TestAccessBio CareStart 2-packs At Home TestCelltrion Dia Trust COVID-19 Rapid AntigenCue’s COVID-19 Test for Home and OTC UseEllume’s COVID-19 Home TestFlowflex Antigen SARS-covid-19 Rapid TestiHealth COVID-19 Antigen Rapid TestIntrivo Diagnostics On/Go At-Home TestLucira’s COVID-19 All-In-One Test KitQuidel’s QuickVue At-Home OTC COVID-19 Test
10. What is your gender identity?*

    1. Male
    2. Female
    3. Nonbinary or genderqueer
    4. Questioning/Unsure of gender identity
    5. Prefer not to answer
11. How old are you?*
    -- Select One --0-4 years old5-11 years old12-15 years old16-19 years old20-29 years old30-49 years old50-64 years old65-74 years old75+ years old
13. What is your race? (Mark all that apply)*

    1. American Indian or Alaska Native
    2. Asian
    3. Black or African American
    4. Native Hawaiian or other Pacific Islander
    5. White
    6. Another race
14. Are you Hispanic, Latinx, or of Spanish origin*

    1. Yes
    2. No
16. Zip*
18. Agreement

    1. I agree to share the above information with the Brookline Health Department.

20. If you or a member of your household tested positive for COVID-19, that person should stay home, isolate away from others in the household if possible, and only leave the home for urgent medical appointments. Please notify any close contacts who may have been exposed so that they can get tested or quarantine per CDC guidelines. For more detailed information regarding isolation and quarantine, please visit mass.gov/isolate. You may call the state 2-1-1 line or visit mass211.org for COVID-19 questions not specific to the Town of Brookline. 

    If you have additional questions, you may call the Brookline Public Health Department COVID-19 Case Investigator at (617) 730-2324. If we are unavailable, please leave a message and we will return your call as soon as possible. Thank you very much for helping to keep Massachusetts safe.

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22. 1. Receive an email copy of this form.
23. Email address

    This field is not part of the form submission.

24. Submit

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