Quarantine Letter Request Form

Quarantine Letter Request Form
This intake form should only be completed by/for residents of Monroe County (Wisconsin) who have been identified as a close contact for a confirmed case of COVID-19.

"Close contact" is defined as:
- Had direct physical contact with the person (for example, a hug, kiss, or handshake).
- Were within 6 feet of the person for a total of more than 15 minutes in a single day (includes a single encounter or multiple encounters within a single day adding up to 15 minutes or more).
- Had contact with the person's respiratory secretions (for example, coughed or sneezed on; contact with a dirty tissue; shared a drinking glass, food, towels, or other personal items).
- Live with the person or stayed overnight for at least one night in a house with the person.
Someone is considered "infectious" beginning 48 hours before symptoms started through the date that they are released from isolation, or for cases who didn't have symptoms when they were tested, 48 hours before their test specimen was collected that returned positive.

Please provide the requested information below. Sharing it will help us to ensure quick protection of you, your family, friends, and our community. Your information will be kept confidential and nobody but the health department will have access to your responses. Thank you for your help.

For more information on COVID-19 exposure guidance, visit https://healthymonroecowi.org/covid-19/
Date*

MonthDayYear
Date
Are You a Monroe County (Wisconsin) Resident?*

YesNo

Name*

First NameLast Name
What is Your Date of Birth?*

MonthDayYear
Date
Phone Number*

Area CodePhone Number
What is Your Address?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Have you been notified that you had close contact with a confirmed case of COVID-19 and need to quarantine?*

YesNo
What is the name of the individual who tested positive?*

First NameLast Name
When was your last date of contact with the individual? (If you had multiple encounters with this individual, pick the most recent date)*

MonthDayYear
Date
How Would You Like This Letter Sent to You?*

E-mailMail
What Is Your E-mail Address?*
What is Your Mailing Address?*

This form is only for residents of Monroe County (Wisconsin). If you are a close contact of someone living in Monroe County and need documentation, please call us at 608-269-8666 or contact the health department for the county in which you live.
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