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.