Isolation Orders Request

Complete if you or your child has tested positive for COVID-19 and have been in isolation.

As per CDC guidance, since I or my child tested positive for COVID-19, I or my child must isolate for five (5) days from the onset of COVID-19 symptoms OR from the date of the positive COVID-19 test if asymptomatic. Day 1 of isolation begins the day after I or my child became symptomatic OR the day after I or my child tested positive if I or my child were asymptomatic. On day 6, if symptoms are resolving and there is no fever, isolation is complete. I or my child will continue to wear a mask for 5 additional days.

Your Name

First

Middle

Last

Suffix

Your Address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Your Phone Number

Your Email Address

Please confirm your Email Address

Please confirm your Email Address by entering it here too.

COVID-19 Test Information

COVID-19 Test Type

Date of Test

Were symptoms present prior to test date?

Date of Symptom onset

Name of COVID-19 Positive Person

First

Middle

Last

Suffix

Date of Birth of COVID-19 Positive Person

Your Signature

Sign above.

Note: Your signature does not have to be acknowledged by a notary public; you are swearing to the veracity of the information you have provided on the form.

Please note to save your Isolation Order on the next page as email may not be reliable.

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Isolation Orders Request