COVID-19 Five Day Isolation Order Form

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
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
Gender
Did you complete a COVID-19 test at home or did a lab complete your test? *

Home Test Lab Test
Do you have symptoms? *

Yes No
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
Date of Onset of Symptoms

Month Day Year
Please select:
Last Day of Isolation:
This field will AUTO CALCULATE isolation end date as 5 days after the date of onset of symptoms.
SECTION II: COMPLETE IF YOU DO NOT HAVE SYMPTOMS
Date of Positive COVID-19 Test

Month Day Year
Please select:
Last Day of Isolation:
This field will AUTO CALCULATE isolation end date as 5 days after the date of positive COVID-19 test.
SECTION III: VACCINATION STATUS
I have had the following:

Pfizer vaccine (1 dose) Pfizer vaccine (2 doses) Pfizer vaccine (2 doses plus 1 booster) Moderna vaccine (1 dose) Moderna Vaccine (2 doses) Moderna Vaccine (2 does plus 1 booster) Johnson & Johnson (1 dose) Johnson & Johnson (1 dose plus 1 booster) Unvaccinated
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.
Attestation *

By selecting this bullet, I hereby affirm, under the penalties of perjury, that all information provided by me on this COVID-19 Isolation Order 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 *
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.
Should be Empty:

COVID-19 Five Day Isolation Order

SECTION I: IDENTIFICATION

SECTION II: COMPLETE IF YOU HAVE SYMPTOMS

SECTION II: COMPLETE IF YOU DO NOT HAVE SYMPTOMS

SECTION III: VACCINATION STATUS

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