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Business Reporting COVID-19 Positive Case

Please use this secure form to report COVID-19 positive employees/individuals to the Washtenaw County Health Department. After submitting this survey, we will contact you if we require additional information.

Please complete a separate form for each positive individual you are reporting for your facility. 
2. Business/location information: *This question is required.
3. Business point of contact: As personal health information is shared, the business point of contact should be a manager or member of human resources, and not a co-worker. *This question is required.
6. Type of Business/Location:
7. COVID-19 Positive Employee: Please complete the following information for the positive individual. Leave any sections blank that you do not know.
8. Contagious Time Period: Individuals are contagious starting 2 days before symptoms begin (or if they do not have symptoms, 2 days before they are tested), and continue being contagious for at least 10 days. Please list the dates and times the employee worked while contagious.
9. Close Contacts: A close contact is someone who was closer than 6 feet for 15 minutes or more (cumulative time throughout the day), to the COVID-19 positive person during their contagious period, either with or without wearing masks. 

Are there any close contacts to the COVID-19 positive individual?
10. List any close contacts here. If you do not know this information yet, please submit the form and we will follow up with you. If there are more than 10 close contacts, please email the full list to: 

Close contacts of a COVID-19 positive individual (less than 6 feet apart for 15+ minutes total) must quarantine at home for at least 10 days after their last date of contact with the COVID-19 positive individual. Even if these close contacts test negative for COVID-19, they must still complete the full 10 day quarantine at home. They can return to in-person work at the end of this timeframe (i.e. on day 11) as long as they have not developed any symptoms, have not tested positive, and do not have pending test results.

Quarantine Exemptions: Individuals identified as close contacts may be considered exempt from quarantine ONLY if they meet one of the criteria defined below. If one of the close contacts you are reporting qualifies as exempt from quarantine, please still include this individual and their contact details on the list below. In the "other information" column make note of which quarantine exemption they qualify under (fully vaccinated or tested positive in past 90 days).
  • Close contacts who have tested positive for Covid-19 within the past 90 days do not need to quarantine as long as they do not have ANY symptoms since their exposure.
  • Close contacts who are fully vaccinated for Covid-19 (it has been more than 14 days since their 2nd dose of Pfizer/Moderna, or more than 14 days since their only dose of Janssen/Johnson & Johnson) do not need to quarantine as long as they do not have ANY symptoms since their exposure. Fully vaccinated close contacts are recommended to test 3-5 days after exposure, and wear a mask for 14 days after exposure or until negative test results are available. 
Space Cell Name (first and last)Parent or Guardian name (if close contact is a minor)Date of last contact with the positive personPhoneEmailCounty of residenceCovid-19 vaccination date(s)Any other information you want to share
Close contact #1
Close contact #2
Close contact #3
Close contact #4
Close contact #5
Close contact #6
Close contact #7
Close contact #8
Close contact #9
Close contact #10
Name of person you talked to & Date
12. Please share the steps your business has already taken in response to being notified about this positive employee: