Positive Case Reporting

Staff Positive Case Reporting Form

If you have questions or concerns, please contact Darryl Clay at dclay@briya.org
Name*

First NameLast Name
Mobile Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
YesNo
Test Date*

MonthDayYear
Date
YesNo
If not, what date did you test positive for COVID-19 previously? *

MonthDayYear
Date
What date did you notify Briya?*

MonthDayYear
Date
When was your last day at Briya?*

MonthDayYear
Date
YesNo
What date did you start feeling symptoms?*

MonthDayYear
Date
YesNo
Click (https://form.jotform.com/220058626069053) for additional information about close contacts
Please list the first and last name of each person with whom you were in close contact. Also, include each person’s phone number and the last date you were in close contact.
Full Name of Close Contact*
First name Last name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Last close contact date*

MonthDayYear
Date
YesNo
Full Name of Close Contact*
First name Last name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Last close Contact date*

MonthDayYear
Date
YesNo
Full Name of Close Contact*
First name Last name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Last close contact date*

MonthDayYear
Date
YesNo
Full Name of Close Contact*
First name Last name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Last close contact date*

MonthDayYear
Date
Should be Empty: