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COVID-19 Self-Reporting Form for the General Public

The Livingston County Health Department understands that individuals with COVID-19 may need a letter to return to work. Please complete the form below. Submission can be completed by clicking the "SUBMIT" button on the form. Questions about this form can be submitted to the LCHD COVID-19 email: 

Once the survey is complete and laboratory results have been received, a LCHD representative will email you the letter requested within 2 business days
Please provide the following required information. 
This question requires a valid date format of MM/DD/YYYY.
This question requires a valid number format.
This question requires a valid email address.
This question requires a valid date format of MM/DD/YYYY.
Enter the following information about your test location *This question is required.
Email a picture of your laboratory result to LCHD at LCHD will only be able to provide you a letter after you email your laboratory results. If you do not have a copy of your laboratory results, contact your test location. 

In order to assist LCHD staff in sending letters, please enter your First Name and Last Name in the subject line of the email. 

Have you already emailed your lab results to LCHD? *This question is required.
Were you in close contact with individuals during your contagious period?

See the definitions below to help make determine your answer to this question. 

Close Contact
LCHD considers a close contact to be someone that has been within 6 feet of a contagious individual for at least 15 minutes of cumulative time.

Contagious Period
LCHD considers a person with COVID-19 to contagious 2 days before symptoms appear (or 2 days before positive test, if no symptoms), through the end of the isolation period.  *This question is required.
Enter your close contacts during your contagious period. 
Space Cell NamePhone NumberDate of Last ContactCounty of Residence
Close Contact #1
Close Contact #2