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.
Home Phone Number
Please enter a valid phone number.
Are you a DC resident?*

YesNo
Test Date*

MonthDayYear
Date
Is this your first time testing positive for COVID-19 during the past 90 days?*

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
Did you have symptoms before you were tested?*

YesNo
What date did you start feeling symptoms?*

MonthDayYear
Date
Have you been in close contact with anyone?*

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.
Last close contact date*

MonthDayYear
Date
Do you need to add another person?*

YesNo
Full Name of Close Contact*
First name Last name
Phone Number
Please enter a valid phone number.
Last close Contact date*

MonthDayYear
Date
Do you need to add another person?*

YesNo
Full Name of Close Contact*
First name Last name
Phone Number
Please enter a valid phone number.
Last close contact date*

MonthDayYear
Date
Do you need to add another person?*

YesNo
Full Name of Close Contact*
First name Last name
Phone Number
Please enter a valid phone number.
Last close contact date*

MonthDayYear
Date
Should be Empty: