Covid-19 Form

COVID-19 Release

If you or someone in your household has tested positive for COVID-19 or has been exposed to COVID-19 please complete the following exposure notification form. Your participation helps keep our whole community safe.
Today's Date

MonthDayYear
Child's Name

First NameLast Name
Name of Individual Reporting*

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Today's Date

MonthDayYear
Date
For the following statements, please select Yes or No. "Yes" answers will reveal a field in which to provide a date.
My child or someone in my household came in direct contact with someone with COVID-19

NoYes
Date of Exposure

MonthDayYear
Date
The direct contact was to someone with COVID-19 who is also a member of my child's household

NoYes
Date that person developed COVID-19

MonthDayYear
Date
My child tested positive for COVID-19

NoYes
Date of positive test

MonthDayYear
Date
My child has symptoms of COVID-19

NoYes
Date symptoms began

MonthDayYear
Date
What are/were the symptoms?
Thank you for contacting CI! If you receive results from a COVID-19 test or someone in your household develops symptoms, please contact us at your earliest convenience, 608-819-6394.
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COVID-19 Release