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Business Reporting COVID-19 Positive Case

Please use this secure form to report COVID-19 positive employees/individuals to the Central Michigan District 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. 
This question requires a valid date format of MM/DD/YYYY.
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2. Business Information *This question is required.
3. As personal health information is shared, the business point of contact should be a manager or member of the Human Resources team and not a co-worker. *This question is required.
This question requires a valid number format.
This question requires a valid number format.
6. Type of business/location *This question is required.
7. COVID Positive Employee's Information *This question is required.
8. Do you know if the positive employee has school-aged children? *This question is required.
9. 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. *This question is required.
10. 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. Individuals identified as close contacts must quarantine for 14 days after they were last in contact with the positive person.  Are there any close contacts that have been identified in the workplace for this individual? *This question is required.
11. List any close work contacts here. These individuals must quarantine for 14 days after they were last in contact with the positive person. Even if the close contacts test negative, they must complete the full 14 days of quarantine. If you do not know this information yet, please submit the form and we will follow up with you.
Space Cell Name (first and last)Date of last contact with the positive personPhoneEmailCounty of residence (if known)Any other information you would like to share
Close Contact #1
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Close Contact #3
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Close Contact #5
Close Contact #6
Close Contact #7
Close Contact #8
Close Contact #9
Close Contact #10
13. Please share the steps that your business has already taken in response to being notified of this positive employee *This question is required.
  • * This question is required.
14. Does your business need/want a return call from Central Michigan District Health Department?  If so, please indicate the reason.
  • * This question is required.