NEW EMPLOYEE OR EXISTING EMPLOYEE? NEW EMPLOYEE OR EXISTING EMPLOYEE? NEW EMPLOYEE (FIRST TEST @ ALL CARE) EXISTING EMPLOYEE

FIRST NAME

MIDDLE NAME (BLANK IF NONE)

LAST NAME

ADDRESS

CITY

STATE

ZIP CODE

DATE OF BIRTH (MM/DD/YYYY)

PHONE NUMBER

FEMALE MALE

PREGNANT NOT PREGNANT

RACE (OPTIONAL) RACE (OPTIONAL)AMERICAN INDIAN OR ALASKA NATIVEASIANBLACK OR AFRICAN AMERICANNATIVE HAWAIIAN OR OTHER PACIFIC ISLANDERWHITEOTHER

ETHNICITY (OPTIONAL) ETHNICITY (OPTIONAL)NOT HISPANIC OR LATINOHISPANIC OR LATINO

TEST RESULT TEST RESULT NEGATIVE POSITIVE

TEST USED TEST USED ABBOT BINAX NOW BD VERITOR PLUS OTHER

OTHER TEST USED

TEST PERFORMED BY

LIST ANY SYMPTOMS (BLANK IF NONE)