Quarantine Orders Request

Complete if you or your child have come in close contact with a positive COVID-19 case.

As per CDC guidance, since I or my child came in close contact with a COVID-19 Case, I or my child must quarantine for five (5) days from the date of the last contact with the positive COVID-19 Case. Day 0 of quarantine began the last day I or my child were in close contact with a positive COVID-19 Case. On day 6, quarantine is complete. I or my child will seek a COVID-19 test and continue to wear a mask for 5 additional days should symptoms develop.

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 Contact Tracing

Name of Unvaccinated Individual requiring quarantine

First

Middle

Last

Suffix

Date of Birth of Quarantined Person

Name of COVID-19 Positive Person

First

Middle

Last

Suffix

Date of last contact with COVID-19 Positive Case

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.

Search

Quarantine Orders Request