Business/School Report form for a Positive Employee/Student

If a worker/volunteer tests positive for COVID-19 in New York State, the employer/school must immediately notify state and local health departments and cooperate with contact tracing efforts, including notification of potential contacts, such as workers, students or visitors who had close contact with the individual, while maintaining confidentiality required by state and federal law and regulations.

Please complete and submit the following form for each of your employees/students that test positive for COVID-19. You may be contacted by a Schenectady County Public Health Services employee if more information is needed. Thank you for your assistance.

Organization Information

Type of Organization

Organization Name

Address

City/Town

State/Province

ZIP/Postal Code

First

Middle

Last

Phone Number

COVID-19 Positive Case Information

First

Middle

Last

Suffix

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Positive Individual's Phone Number

Date of First Symptom

Leave blank if not applicable

Additional Dates at Work While Symptomatic

Last Day of Work

Potentially Exposed Contacts (Please add Full Name/DOB/Address/Phone Number if possible)

Date of COVID Test

Leave blank if not applicable