COVID-19 Mandatory 5-Day Quarantine Form

COVID-19 Five-Day Quarantine Order

Please complete all fields as they apply to you. Fields marked with an asterisk (*) are required fields.
Use this form to create a quarantine order if you were exposed to COVID-19 by being a close contact to someone who has tested positive.

A close contact is someone who has been within 6 feet of a person with COVID-19 for 15 minutes or more when one or both were not wearing a properly fitting mask.

This document will serve as both your quarantine order and release from quarantine at the end of the quarantine period, as long as you do not have an additional exposure during the quarantine period. If you have continuous exposure to someone who has tested positive for COVID-19 (such as a young child you care for), you must quarantine for an additional 5 days beyond the end of that person's isolation.
Instructions and information for mandatory quarantine:
- Remain at home and away from others for five days from your last contact with the person who has COVID-19.
- Wear a well-fitting mask at home and ask household members to do the same to decrease the likelihood of spread if you develop COVID-19.
- Mask for an additional 5-days (through day 10 after exposure) while interacting with others. If you are unable to wear a mask correctly and consistanly, you need to quarantine for 10-days. Complete the Ten-Day Quarantine Order Form.
- Test yourself for COVID-19 on day-5 or if you develop symptoms. A home test, lab test, or pharmacy test are all acceptable. If positive, remain at home another 5-days. If you need a 5-day isolation order, go to Isolation Order Form .
Name *

First Name Middle Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
E-mail
Please enter a valid email address.
Date of Birth *

Month Day Year
Date
Date of Last Exposure to COVID-19 *

Month Day Year
Please select:
Last Day of Quarantine
This field will AUTO CALCULATE last day of quarantine as 5 days after the date of last exposure to COVID-19.
Attestation *

By selecting this bullet, I hereby affirm, under the penalties of perjury, that all information provided by me on this COVID-19 Mandatory Quarantine Request Form (including any attached photographs or information) are true to the best of my knowledge and belief.
Today's Date

Month Day Year
Date
Please verify that you are human *
DIRECTOR'S ORDER FOR 5-DAY QUARANTINE AFTER EXPOSURE TO SOMEONE WITH COVID-19

WHEREAS MARY BEER, Director of Ontario County Public Health, possesses all the powers and duties of a local health officer pursuant to Public Health Law 352(2) and (356(1).

WHEREAS, The New York State Sanitary Code, 10NYCRR 2.29, provides that whenever a case of highly communicable disease comes to the attention of a county health officer, said officer shall isolate and/or quarantine such afflicted person as in such officer's judgment is deemed necessary; and

WHEREAS, it has come to the attention of Director MARY BEER that the individual completing this form was exposed to COVID-19 Disease, a highly communicable disease as defined by the New York State Sanitary Code, 10NYCRR 2.1; and

WHEREAS, Director MARY BEER has reasonably concluded that this individual be quarantined in such a place, under such conditions and for such time as will prevent transmission of said communicable disease.

NOW, therefore, pursuant to the authority granted by the laws of the State of New York, Director MARY BEER hereby orders and directs the following.

QAURANTINE OF EXPOSED INDIVIDUAL

The individual exposed to COVID-19 shall quarantine for five days as noted in this document.

Mary L. Beer, Director Ontario County Public Health

NOTICE: ANY PERSON WHO WILFULLY VIOLATES OR REFUSES OR OMITS TO COMPLY WITH ANY LAWFUL ORDER OF A LOCAL HYEALTH OFFICER IS GUILTY OF A MISDEMEANOR PURSUANT TO PUBLIC HEALTH LAW 12-b.

You have the right to seek judicial review of this order. You have the right to legal counsel, and if you are unable to afford legal counsel, counsel will be appointed upon request.
IMPORTANT: PRINT THIS FORM FOR YOUR RECORDS AND TO PROVIDE TO YOUR SCHOOL OR EMPLOYER PRIOR TO SUBMITTING THIS FORM!
AFTER you have printed, this form, please finish by clicking the SUBMIT button.

Thank you.
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COVID-19 Five-Day Quarantine Order