COVID 19 Report Form

The information you provide below is contained on a HIPAA Compliant database and confidentially accessed by the Jackson County Health Department in order to streamline COVID 19 case reporting to the local health department. Businesses are recommended to report COVID-19 cases so that we can provide assistance in preventing further cases and outbreaks. The survey will take 5-10 minutes to complete and has all of the resources you need to successfully manage the COVID-19 exposure in your specific location (workplace, long term care, etc.).
The Jackson County Health Department may call you and ask for identifying information, including names and phone numbers, after reviewing your submitted information.

1. What is today's date? This question requires a valid date format of MM/DD/YYYY.

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2. Please provide the following information about the business / school and Point of Contact (PoC) information. The business PoC should be a manager or human resources contact. The school PoC should be someone identified as responsible for communicable disease reporting or a school administrator. *This question is required.

Business / School Name
Street Address
City
State (Default to MI)
Zip
PoC Full Name
PoC Title
PoC Phone
PoC Email Address

4. If other is selected, what type of Business?

4. Please provide the following information for EACH positive COVID-19 case. Select Add Another to add additional people to the list of positive COVID-19 cases for your site. There is no limit.

Positive Employee / Student legal name

Date of Birth

Phone Number

Test Date (MM/DD/YYYY) This question requires a valid date format of MM/DD/YYYY.

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What kind of test was performed?

Symptom Onset Date (MM/DD/YYYY) This question requires a valid date format of MM/DD/YYYY.

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Dates present while contagious (format mm/dd/yyyy, mm/dd/yyyy) Individuals are considered contagious two days before symptoms or two days before test date if asymptomatic.

CDC COVID-19 Isolation Guidance:

Stay home when sick: If you have COVID-19 symptoms, stay home until you've been fever-free for 24 hours without medication AND your other symptoms are mild and improving.
Mask up: Wear a well-fitting mask indoors around others for 10 days after you become sick or test positive (even if you don't have symptoms).
Protect those at higher risk: Avoid contact with people at higher risk for severe COVID-19 for 10 days.

Additional Considerations for Healthcare Settings

Healthcare settings: Different guidelines may apply to healthcare settings.
CDC Healthcare Provider Return to work Recommendations.

Exposure Guidance

If you're a close contact of someone with COVID-19, you do not need to quarantine at home. If symptoms develop, get tested and follow isolation guidance right away. If you don't have symptoms, but are at higher risk of severe illness, you should test within 5 days.

5. Have you notified exposed co-workers / students and asked them to quarantine? Please describe steps taken

Cleaning and Disinfecting Instructions:

Before Cleaning and Disinfecting

Routine Cleaning: For most situations, cleaning surfaces with soap and water is sufficient. This removes germs and significantly reduces the risk of infection.
Disinfecting (within 24 hours of a suspected or confirmed case): If someone with suspected or confirmed COVID-19 has been in the space within the last 24 hours, clean and disinfect the area.
Prioritize frequently touched surfaces: When disinfecting, focus on surfaces that are touched often, like doorknobs, light switches, tabletops, handles, and shared equipment.
If more than 24 hours have passed since the person who is sick or diagnosed with COVID-19 has been in the space, cleaning is enough. You may choose to disinfect depending on specific conditions or everyday practices required by your facility. Disinfection is generally not necessary after 24 hours.
If more than 3 days have passed since the person who is sick or diagnosed with COVID-19 has been in the space, no additional cleaning (beyond regular cleaning practice) is needed.
Always follow product label instructions: When using disinfectants, use them safely and effectively by following the manufacturer's directions.
Ventilation is important: Increasing ventilation (e.g., opening windows, using air filtration) helps reduce the concentration of airborne viruses.
Continue other preventive measures: Cleaning and disinfection should be combined with hand hygiene, staying home when sick, and other recommended precautions.

CDC Safety Precautions: Cleaning and disinfecting for COVID-19

6. Could you please check the boxes below the items to indicate which preventive measures have been put into place.

COVID positive staff / student sent home to isolate
Reported case to local health department
Notified exposed staff / students of exposure
Quarantined exposed contacts away from worksite or school
Cleaning / disinfecting the facility
Encourage COVID Vaccination
Promoting everyday protective measures such as signage, social distancing, mask usage, hand hygiene, etc.
Closed the facility due to COVID

7. Is there any other additional information you would like to provide to us?

CDC Respiratory Virus Guidance: https://www.cdc.gov/respiratory-viruses/guidance/index.html

CDC COVID-19 Guidance and Information: https://www.cdc.gov/covid/index.html

COVID 19 Report Form

COVID Case Report Form