Learning Centers and Schools

Contact Tracing Form
Learning Centers and Schools
Attention Administration: Please expedite a completed separate form for each positive COVID case reported. Provide as much information as possible without substantial delay.
Date

Month Day Year
Date
Completed by
1. School, Location, and Primary Contact Information
Name of Institution
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Hours/Days of Operation
Type or Level
Point of contact
Title or Role
Office Phone
Please enter a valid phone number.
Alternate Phone

Area Code Phone Number
Email
2. Demographics
Total number of staff/employees employed at school
Total number of students who attend the school
Past 2 weeks, how many individuals tested COVID-19 positive?
3. COVID-19 Positive Individuals
Name

First Name Last Name
Minor?
(if applicable) Name of Guardian

First Name Last Name
Date of Birth

Month Day Year
Date
Gender
County of Residence
Phone Number

Area Code Phone Number
Email
example@example.com
(if applicable) Date individual developed symptoms

Month Day Year
Date
Date individual was tested

Month Day Year
Date
Date individual received positive test result

Month Day Year
Date
Date individual last attended

Month Day Year
Date
Date office was notified of positive test result

Month Day Year
Date
4. Contagious Time Period
Please list the dates and times the individual was in attendance with considered contagious

Individuals are considered contagious 2 days before symptoms begin (or if they do not have symptoms, 2 days before they are tested).
Date

Month Day Year
Date
Time
Date

Month Day Year
Date
Time
Date

Month Day Year
Date
Time
Date

Month Day Year
Date
Time
Date

Month Day Year
Date
Time
5. Close Contacts

A close contact is someone who was closer than 6 feet, for 15 minutes or more (cumulative time throughout the day), either with or without masks, to the COVID-19 positive person during their contagious period.

The contagious period begins 2 days before symptoms start, (or 2 days before testing if no symptoms), and goes until the positive person was isolated from others.

Individuals identified as close contacts must quarantine for 14 days after they were last in contact with the positive person.
Are there any close contacts to the COVID-19 positive indivuidal?

Yes (please COMPLETE Section 6 No (Please SKIP Section 6 Unsure (Please skip Section 6. Determine close contact status, and we will follow up with you and obtain this information after you submit this form)
6. List Close Contacts Here.

IMPORTANT: these individuals must quarantine for 14 days starting the day they were last in contact with the positive case. If close contact tests negative, they must complete the full 14 days of quarantine.
Name

First Name Last Name
Minor?
(if applicable) Name of guardian

First Name Last Name
Relationship to Positive Case
Phone Number

Area Code Phone Number
Email
example@example.com
(if known) County of residence
Date of last contact with positive person

Month Day Year
Date
Name

First Name Last Name
Minor?
(if applicable) Name of guardian

First Name Last Name
Relationship to Positive Case
Phone Number

Area Code Phone Number
Email
example@example.com
(if known) County of residence
Date of last contact with positive person

Month Day Year
Date
Name

First Name Last Name
Minor?
(if applicable) Name of guardian

First Name Last Name
Relationship to Positive Case
Phone Number

Area Code Phone Number
Email
example@example.com
(if known) County of residence
Date of last contact with positive person

Month Day Year
Date
Name

First Name Last Name
Minor?
(if applicable) Name of guardian

First Name Last Name
Relationship to Positive Case
Phone Number

Area Code Phone Number
Email
example@example.com
(if known) County of residence
Date

Month Day Year
Date
Name

First Name Last Name
Minor?
(if applicable) Name of guardian

First Name Last Name
Relationship to Positive Case
Phone Number

Area Code Phone Number
Email
example@example.com
(if known) County of residence
Date of last contact with positive person

Month Day Year
Date
Name

First Name Last Name
Minor?
(if applicable) Name of guardian

First Name Last Name
Relationship to Positive Case
Phone Number

Area Code Phone Number
Email
example@example.com
(if known) County of residence
Date of last contact with positive person

Month Day Year
Date
Name

First Name Last Name
Minor?
(if applicable) Name of guardian

First Name Last Name
Relationship to Positive Case
Phone Number

Area Code Phone Number
Email
example@example.com
(if known) County of residence
Date of last contact with positive person

Month Day Year
Date
Name

First Name Last Name
Minor?
(if applicable) Name of guardian

First Name Last Name
Relationship to Positive Case
Phone Number

Area Code Phone Number
Email
example@example.com
(if known) County of residence
Date of last contact with positive person

Month Day Year
Date
Name

First Name Last Name
Minor?
(if applicable) Name of guardian

First Name Last Name
Relationship to Positive Case
Phone Number

Area Code Phone Number
Email
example@example.com
(if known) County of residence
Date of last contact with positive person

Month Day Year
Date
Name

First Name Last Name
Minor?
(if applicable) Name of guardian

First Name Last Name
Relationship to Positive Case
Phone Number

Area Code Phone Number
Email
example@example.com
(if known) County of residence
Date of last contact with positive person

Month Day Year
Date
Name

First Name Last Name
Minor?
(if applicable) Name of guardian

First Name Last Name
Relationship to Positive Case
Phone Number

Area Code Phone Number
Email
example@example.com
(if known) County of residence
Date of last contact with positive person

Month Day Year
Date
Name

First Name Last Name
Minor?
(if applicable) Name of guardian

First Name Last Name
Relationship to Positive Case
Phone Number

Area Code Phone Number
Email
example@example.com
(if known) County of residence
Date of last contact with positive person

Month Day Year
Date
7. Steps your facility has already taken in response to being notified about this COVID positive individual
8. Any other information that could be helpful to St. Clair County Health Department:
Recommendations from the St. Clair County Health Department
- Ensure that sick leave policies are flexible and consistent with public health guidance; permits employees to stay home to care for a sick family member, and those employees are aware of these policies. Actively encourage sick employees stay home. https://www.michigan.gov/documents/leo/leo_miosha_c19_workplace_guidelines_employer_690397_7.pdf
- Monitor employees, volunteers and contractors for acute respiratory illness symptoms (i.e. cough, shortness of breath) upon arrival to facility or become sick during the day. Send symptomatic staff home immediately to follow up with a healthcare provider and/or seek COVID testing. To find a test site visit www.michigan.gov/coronavirus . Employees may return to work if no longer infectious as per CDC, most current guidlines visit www.cdc.gov/coronavirus. Individuals identified as close contacts must complete quarantine cycle regardless of lack of symptoms and/or negative test results
- Upon notification of a COVID positive employee, customer, volunteer, or contractor; the employer shall complete a Contact Tracing Worksheet, and within 24 hrs. notify any co-workers, contractors, volunteers, or customers who were identified as a close contact with the COVID positive individual. Submit electronically on www.scchealth.co –or-Secure Fax: 810-985-4340 -or- Email: healthdepartmentcontacttracing@stclaircounty.org.
- Continue to minimize exposure between healthy employees and between those employees and the public. Put safeguards in place. Assure protocols are followed on all shifts at all times. www.michigan.gov/miosha
- Provide adequate and accessible facemasks and hand sanitizer with high profile signage to remind all staff, customers, contractors, and visitors where masking is required. Examples: “Help our business stay open – please wear a mask” –or- “We are sorry, we cannot serve/service you if you are not properly masked”.
- Signage available at www.scchealth.co AND www.cdc.gov/coronavirus
Visit www.scchealth.co for information and updates.

St. Clair County Health Department COVID-19 Informational Hotline:

(810) 966-4163

COVID19@stclaircounty.org
Should be Empty:

Contact Tracing Form

Learning Centers and Schools