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  • COVID-19 Five Day Isolation Order

    Please complete all fields as they apply to you. Fields marked with an asterisk (*) are required fields.
  • Instructions for 5-day Isolation:

    • Remain at home and away from others for five days.
    • Do not prepare food for others or eat within 6 feet of household members.
    • Sleep in a room by yourself and use a separate bathroom. If you can’t use a separate bathroom, clean high touch areas with disinfecting wipes between uses.
    • Wear a well-fitting mask at home and ask household members to do the same to decrease the likelihood of spread.
    • Continue to mask for an additional 5 days (through day 10) after your isolation period ends. If you are not able to mask correctly and consistantly or have significant immune compromise, complete a Ten-Day Isolation Order Form .
    • If on day 5, you are still very sick or have a fever of over 100 degrees, notify your healthcare provider and stay home for another 5 days. Use the link above if you need a Ten-Day Isoaltion Order Form.
    • If you develop chest pain, shortness of breath with dizziness, confusion, or difficulty breathing, call 911.
  • SECTION I: IDENTIFICATION

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  • COVID-19 Symptoms include:

    • Cold-like symptoms, runny nose, headache, congestion, sore throat, cough;
    • Fever;
    • Body aches or excessive fatique,
    • Chest pain, shortness of breath or difficulty breathing;
    • Nausea, vomiting, diarrhea.
  • SECTION II: COMPLETE IF YOU HAVE SYMPTOMS

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  • SECTION II: COMPLETE IF YOU DO NOT HAVE SYMPTOMS

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  • SECTION III: VACCINATION STATUS

  • SECTION IV: DIRECTOR'S ORDER FOR 5-DAY ISOLATION

  • 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 noted on this form, is a person afflicted with 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 should be isolated 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.

    THE INDIVIDUAL NOTED ON THIS FORM TO HAVE COVID-19 INFECTION SHALL ISOLATE 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 HEALTH 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.

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  • IMPORTANT: Print this document for your records and to provide to your school or employer PRIOR to submitting!

  • After printing this form, please finalize by clicking the SUBMIT button.

    Thank you.

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