Isolation Form – Ulster County COVID-19 Information

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First Name *

Middle Initial *

Last Name *

Suffix

Occupation

Last Date Worked *

Date Symptoms Started *

Date Symptoms Ended *

Last Close Contact Date

Checkboxes

Never in Close Contact

Date Last in Restricted Location

No Restricted Travel

Address *

Address 2

City *

State

Zip *

County *

Gender *

Date of Birth *

Home Phone

Cell Phone

Work Phone

Trip Details Narrative

Certify1 *

I certify that it has been at least 14 days since I had close contact (within 6 feet for a minimum of 10 minutes) with a person who was infected with COVID-19.

Certify2 *

I certify that since my last exposure I have been symptom free from: fever, cough, shortness of breath and any other respiratory distress without the use of fever reducing medications.

Certify3 *

I certify that I have been fever free for at least 3 days (72 hours) and have not taken any fever-reducing medication (such as Tylenol) in that same period of time.

Certify4 *

I certify that any respiratory issues I have suffered have improved.

I UNDERSTAND THAT IF I RECEIVE A RELEASE LETTER, THIS ONLY RELEASES ME FROM RESTRICTIONS IMPOSED BY THE ULSTER COUNTY DEPARTMENT OF BEHAVIOR AND COMMUNITY HEALTH AND DOES NOT RELEASE ME FROM ANY OTHER RESTRICTIONS RELATED TO COVID-19 IMPOSED BY THE STATE OF NEW YORK

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