COVID-19 Case Report

This form is used for reporting COVID-19 case reports. Please complete the form to the fullest you are able.

Date of Report *This question is required. This question requires a valid date format of MM/DD/YYYY.

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Reported By: *This question is required. Please enter the name of the person completing the form.

Reporter Phone Number: *This question is required.

Reporting Facility Name: *This question is required.

Is the reporter the same as the reporting facility's provider?Examples of reporting facility providers include: school nurse, director of nursing, medical director, infection preventionist, etc.

Reporting Facility Provider Name:

Reporting Facility Provider Phone Number: