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

Month Day Year
Child's Name

First Name Last Name
Name of Individual Reporting *

First Name Last Name
Phone Number

Area Code Phone Number
Email
example@example.com
Date of Exposure

Month Day Year
Date
For the following statement please check all that apply.

My child or someone in my household came in direct contact with someone with COVID-19 My child or someone in my household is on quarantine My child has symptoms of COVID-19 My child tested positive for COVID-19
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