COVID-19 Positive Rapid Antigen Test Self-Reporting Form

Step 1 - Screening
Step 2 - Details
Step 3 - Declaration

Thank you for reporting your positive rapid antigen test.

If you are a parent, legal guardian or authorised carer, you can fill in this form for your child or someone you care for.

If you are a health professional, you can complete the online form on behalf of your patient or client.

Answering these questions will help keep you and your community safe. Please answer honestly and completely so we can make sure you get the right support.

Your personal information is kept safe and is protected by legislation. Information is only shared where needed to protect public health. For more information visit www.health.vic.gov.au/privacy

If you are experiencing technical difficulties or need assistance completing this form, you can call 1800 675 398 between 9am-4pm. Interpreter services are available.

Who are you reporting this Positive Result for?

MyselfFor another person

Your (Reporters) First Name

Your (Reporters) Last Name

Contact Number

Relationship to person you are filling in the form for

For all Aged Care residents, please select ‘Aged Care Resident’

Name of facility/company

If you have done multiple Rapid Antigen Tests, please only enter the date of your FIRST positive test.

Please do not report a negative rapid antigen test result.

Date positive test was taken

Have you recently been in known contact with someone who has COVID-19?

NoYes

Have you been recently unwell with COVID-19 symptoms?

(fever, cough, tiredness, runny or blocked nose)

NoYes

What date did you first have symptoms from this infection?

Was this Rapid Antigen Test provided as part of an education (school or early childhood) screening program?

NoYes

Generate a new image Play the audio code

Enter the code from the image