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 https://www.coronavirus.vic.gov.au/privacy-vicgovau

If you need to talk to someone about this survey in another language, please call 1800 675 398 (press 0 for an interpreter).

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

Name of facility/company

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

If you have recovered from COVID-19, you are not required to get tested or isolate/quarantine if you are re-exposed to a case within 4 weeks of ending your isolation period.
During these 4 weeks, if you get new symptoms, we recommend you stay at home until your symptoms resolve. If you are at a high risk of severe illness, get tested.
After 4 weeks, you must follow the relevant advice depending on the type of contact you are.

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, loss of taste or smell)

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

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