Cnyfamilycare - SELF-ATTESTATION: AFFIRMATION OF QUARANTINE

SELF-ATTESTATION: AFFIRMATION OF QUARANTINE

(Complete one form for each person)
Complete this form if you or your child:
1. Have been identified as a close contact to a COVID-19 positive person during their contagious period, and
2. Was not fully vaccinated at the time of exposure to a COVID-19 positive person during their contagious period, and
3. Have been in quarantine
Name *
Quarantine Start Date *

Month Day Year
Date
Quarantine End Date *

Month Day Year
Date
I, __{name}__, do hereby affirm that I or my child quarantined from __{quarantineStart}__ through __{quarantineEnd}__ consistent with guidance issued by the New York State Department of Health (NYSDOH) and Centers for Disease Control and Prevention (CDC). As per NYSDOH and CDC guidance, I or my child was identified as a close contact to a COVID-19 positive person during their contagious period and was not fully vaccinated at the time of exposure. I or my child quarantined for at least five (5) days (where day zero is the last day of exposure) and have:
1. Remained asymptomatic during the five (5) days OR
2. Developed symptoms but tested negative on a COVID-19 antigen or PCR test.
I understand that a well-fitting mask should be worn around others for 10 days following the date of exposure.
Name of Person in Quarantine *
Date of Birth of Person in Quarantine *

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

Month Day Year
Date
Affirmed under penalties of perjury by me on (today’s date) *

Month Day Year
Date
Signature *

Clear
PLEASE NOTE: YOUR SIGNATURE DOES NOT HAVE TO BE WITNESSED BY A NOTARY PUBLIC; YOU ARE AFFIRMING TO THE VERACITY OF THE INFORMATION YOU HAVE PROVIDED ON THE FORM.

If completed fully and accurately, based solely on such provided information which I accept as fact, I, Indu Gupta, Commissioner, Onondaga County Health Department, do hereby find that the affirming individual herein has met the criteria for quarantine if the date this form is affirmed is more than required number of days (as consistent with the above requirements) from the listed quarantine period onset date.

Indu Gupta MD, MPH
Commissioner of Health

This form may be used for Quarantine Release or for New York Paid Family Leave COVID-19 claims as if it was an individual Order for Isolation issued by the Onondaga County Health Department Commissioner of Health.
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