COVID-19 Screening

This questionnaire is designed to gather information regarding the COVID-19 pandemic currently affecting our country and offer guidance and instruction to ensure your safety.

Birthday

First Name

Middle Name

Last Name

Suffix

Gender

Street 1

Street 2

City

State/Province

County

Postal Code

Mobile Phone

Preferred Contact Method

I hereby consent and state my preference to have the State of North Dakota, and its staff, communicate with me by email or standard SMS messaging regarding my COVID-19 test results and any additional relevant medical information. The email address or telephone number I would like to receive SMS messaging at is as provided above.

I understand that email and standard SMS messaging are not confidential methods of communication and may be insecure. I further understand that, because of this, there is a risk that email and standard SMS messaging regarding my test results might be intercepted and read by a third party.

I understand this authorization is voluntary, and the State of North Dakota Community Based Testing Sites may not condition testing on whether I sign this Authorization. This Authorization remains in effect for five years from the date hereof unless specifically revoked by written notice to the State of North Dakota, except to the extent that action has been taken in reliance on this authorization.

I agree to receive my results via SMS or email

NoYes