[City of El Paso] Covid-19 Antibody Testing Form

What is your Date of Birth?

Select the group that best describes your occupation. (Optional)

Other

Place of employment

Position. (Optional)

Address

City

State

Zip

Phone Number

Race/Ethnicity

Other

Sex

Male

Female

Have you had COVID-19 symptoms?

Yes

Chills

Fatigue

Muscle or body aches

Headaches

New loss of taste or smell

Sore throat

Congestion or runny nose

Nausea or vomiting

Within the last two weeks

Within the last three weeks

Within the last four weeks

Within the last 2 months

Ever had a COVID-19 Test

Have you tested positive for COVID-19?

Yes

Within the last two weeks

Within the last three weeks

Within the last four weeks

Within the last 2 months

Do you live or work closely with someone who has tested positive for COVID-19?

Yes

Have you gotten a first dose of the COVID-19 vaccine?

Yes

When did you get your first dose?

Have you gotten fully vaccinated (1st and 2nd dose) of the COVID-19 vaccine?

Yes

When did you get your second dose?