Return to Work Request Letter

Return to Work Request Letter

If the Department of Health has contacted you regarding your status as a close contact to someone who has tested positive for Covid – 19 or if you have tested positive for Covid-19 you may request an employer letter. This is for individuals only – employers may not request a letter for their employee (s).
Name: *

First Name Last Name
Phone Number *

Area Code Phone Number
Date of Birth: *

Month Day Year
Date
How would you like your letter delivered? You may selected both options if preferred. *

personal email home address
How would you like your letter delivered?

email mailed
Individual's Email:
You must provide a personal email. Letters will not be sent to an employer.
Individual's Home Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
If known, please provide your DOH Case ID Number?
This number is 9 digits.
If known, Disease Intervention Specialist's Name:
Should be Empty: