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
Your Address
COVID-19 Contact Tracing
Name of Unvaccinated Individual requiring quarantine
Name of COVID-19 Positive Person

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.