Cnyfamilycare - SELF-ATTESTATION: AFFIRMATION OF ISOLATION

SELF-ATTESTATION: AFFIRMATION OF ISOLATION
Complete if you or your child has tested positive for COVID-19 and have been in isolation. Use a separate form for each positive person. Do NOT submit to the Health Department—this form is for your use as legal documentation of your isolation and for New York Paid Family Leave COVID-19 claims.
Name*
Quarantine Start Date*

MonthDayYear
Date
Quarantine End Date*

MonthDayYear
Date
I, __{name}__, do hereby affirm that I or my child isolated from __{quarantineStart}__ through __{quarantineEnd}__ consistent with guidance issued by the New York State Department of Health (NYSDOH). As per NYSDOH guidance, since I or my child tested positive for COVID-19, I or my child remained isolated from other people for at least five (5) days from the onset of COVID-19 symptoms OR from the date of the positive test if asymptomatic, whichever date is earlier (where day 0 is the day of symptom onset or the day I or my child tested positive if asymptomatic). I am or my child is symptom free, or symptoms have improved. I or my child has been fever-free for 24 hours without the use of fever-reducing medications. I understand that a well-fitting mask should be worn around others for a total of 10 days from my or my child’s symptom onset or positive test if asymptomatic.
Name of COVID-19 Positive Person*
Date of Birth of COVID-19 Positive Person:*

MonthDayYear
Date
Date of Specimen Collection for Positive Test*

MonthDayYear
Date
Symptom Onset Date (if earlier from Date of Specimen Collection for Positive Test)*

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

MonthDayYear
Date
Signature*

Clear
PLEASE NOTE: YOUR SIGNATURE DOES NOT HAVE TO BE WITNESSED BY A NOTARY PUBLIC: YOU ARE SWEARING 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 isolation if the date this form is affirmed is more than 5 days from the listed isolation period onset date.

Indu Gupta MD, MPH
Commissioner of Health

This form may be used for Isolation 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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