COVID-19 Positive Case Report Form

COVID-19 Positive Case Report Form
Thank you for reporting this positive COVID-19 case. Your partnership helps the SJCC mitigate the spread of COVID-19 in our community.

Please note: the identity of the person with the positive case will be kept confidential and is used only to determine program participation and a list of close contacts.
Name of person reporting*

First NameLast Name
Name of person with positive test result*

First NameLast Name
SelfParent/GuardianOther
Email of person reporting*
example@example.com
Phone Number of person reporting*

Area CodePhone Number
Please answer the following questions as they relate to the person who has tested positive for COVID-19.
YesNo
Date symptoms began*

MonthDayYear
Date
Test date (not the date test results were received)*

MonthDayYear
Date
YesNo
Thanks for sharing this information. Based on your answers, the person with the positive test result was not in the building during the infectious period, so no more information is needed at this time. You do not need to complete this form. We hope they feel better soon and thank you for your partnership in helping keep our community healthy.
Last date person was at the SJCC*

MonthDayYear
Date
Early Childhood SchoolSwim LessonLap Swim/Family SwimFitness Center/Basketball Gym/Racquetball CourtJ Kids Program (enrichment class, School's Out Camp, Summer Camp, Kidstown)Fitness Class or Other SJCC ProgramThis person is an SJCC employee
If you answered Fitness Class or Other SJCC Program above - or you have additional information to share, like the time you swam or worked out - please tell us the class name or provide details here.
Other than people in a registered program, are there individuals you know this person came into contact with during their last two days at the J?
Should be Empty: