MMDG COVID-19 Report
If you are a parent/guardian or staff member completing this form on behalf of someone else, complete this form as though "I" is the person that was exposed, tested positive or is symptomatic.
Are you submitting this form on behalf of yourself or someone else?
*
Myself
Someone else (another MMDG student, employee or renter)
Name of person exposed, positive or symptomatic
*
First Name
Last Name
Name of person reporting (if different)
First Name
Last Name
Name of employee submitting report on behalf of someone else (if applicable)
First Name
Last Name
Email address [of exposed, positive or symptomatic person or guardian]
*
example@example.com
Phone Number [of exposed, positive or symptomatic person or guardian]
*
Please enter a valid phone number.
I am completing this form because:
*
I was exposed to someone who tested positive for COVID-19
I have tested positive for COVID-19
I have COVID-19 symptoms but have no known exposure and am awaiting my test results
Other
Were you at the Dance Center within the last 48 hours?
*
Yes
No
What date were you last at the Dance Center?
*
-
Month
-
Day
Year
Date
What activity were you participating in at the Dance Center? (Ex: class name, rental group name, who you were meeting)
*
If you were exposed to someone who tested positive, when were you exposed?
-
Month
-
Day
Year
Date
If you tested positive for COVID-19, what date did you get tested?
-
Month
-
Day
Year
Date
Did you get a PCR or a rapid antigen test?
PCR
Rapid antigen
If you are symptomatic, when did your symptoms begin?
-
Month
-
Day
Year
Date
If you tested positive, are you vaccinated?
*
Yes, fully vaccinated
Yes, but not fully vaccinated
No
NA
*
I understand that I am responsible for informing close contacts.
(Staff only) - I give MMDG permission to share my name with proximate contacts.
*
Yes
No
What is a close contact?
Per NYC Department of Health: A close contact is someone who has been within 6 feet for at least 10 minutes over a 24-hour period of someone who has COVID-19 during their infectious period, regardless if face masks were worn or plexiglass or other barriers were used. Additionally, other people may be considered close contacts in certain situations, including: when physical distancing cannot be consistently monitored or maintained; when people are participating in activities that require deeper breathing that can lead to the release of more respiratory droplets or particles (such as vigorous exercise, singing, or playing wind or brass instruments) in an enclosed space.
Submit
Should be Empty: