Individual Form

Contact Tracing Form
IMPORTANT: A person with a positive COVID-19 test must isolate for 10 days.

You can be with others after
- At least 10 days since symptoms first appeared AND
- At least 24 hours with no fever without fever-reducing medication AND
- Other symptoms of COVID-19 are improving**Loss of taste and smell may persist for weeks or months after recovery and need not delay the end of isolation
Name

First Name Last Name
Gender (Given at birth)
Date of Birth

Month Day Year
Date
Ethnicity (check all that apply)

Hispanic/Latino Non-Hispanic/Latino Arab Non-Arab Unknown
Race (check all that apply)

Caucasian Black/African American American Indian/Alaska Native Hawaiian/Pacific Islander Asian Unknow Other
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent/Guardian (required if under 18)

First Name Last Name
Symptomatic?

Yes No
If symptomatic, when did symptoms start?

Month Day Year
Date
Date of test

Month Day Year
Date
Were you in quarantine when symptoms started?

Yes No
(if applicable) Has workplace been notified

Yes No Not Applicable
(if applicable) Has school been notified

Yes No Not Applicable
Name of school and/or workplace
Name of school and/or workplace (if applicable, please name both)
Address of school or workplace

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Address of school or workplace (If applicable)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Do you know where you were exposed?

Yes No
If yes, where, and by whom?
List Close Contacts Here

A close contact is someone who was closer than 6 feet, for 15 minutes or more -this is cumulative time throughout the day- 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.

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
Relationship to contact:
Minor?

Yes No
Parent/Guardian (required if under 18)

First Name Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
(If known) county of residence
Date of last contact

Month Day Year
Date
Name

First Name Last Name
Relationship to contact:
Minor?

Yes No
Parent/Guardian (required if under 18)

First Name Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
(If known) county of residence
Date of last contact

Month Day Year
Date
Name

First Name Last Name
Relationship to contact:
Minor?

Yes No
Parent/Guardian (required if under 18)

First Name Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
(If known) county of residence
Date of last contact

Month Day Year
Date
Name

First Name Last Name
Relationship to contact:
Minor?

Yes No
Parent/Guardian (required if under 18)

First Name Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
(If known) county of residence
Date of last contact

Month Day Year
Date
Name

First Name Last Name
Relationship to contact:
Minor?

Yes No
Parent/Guardian (required if under 18)

First Name Last Name
Relationship to contact:
Phone Number
Please enter a valid phone number.
Email
example@example.com
(If known) county of residence
Date of last contact

Month Day Year
Date
IMPORTANT:

You must isolate for 10 days starting from symptoms onset, if no symptoms, date test was done.
Please add additional close contacts or any other information you think we need to know.
Visit www.scchealth.co for information and updates.

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

(810) 966-4163

COVID19@stclaircounty.org
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Contact Tracing Form