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2. Your Name*
3. Your Preferred Phone #*
5. Your Email Address*
7. Street Address*
9. City*
10. State*
11. ZIP Code*
13. Are you reporting about yourself or a community issue?*

    1. Self Reporting
    2. Community Issue
17. Please describe the community issue you are concerned about.*
19. Are you currently under quarantine?

    1. Yes
    2. No
20. Have you been tested for COVID-19?

    1. Yes
    2. No
22. Have you seen a health care provider?

    1. Yes
    2. No
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24. Submit

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