Isolation Form none First Name *Middle Initial *Last Name *Suffix Sr.Jr.IIIIVVOccupation Food ServiceFood ServiceDay CareHealth CareStudent / SchoolLaw EnforcementGovernmentInmateCorrection WorkerUnemployedRetiredOtherUnknownLast Date Worked *Date Symptoms Started *Date Symptoms Ended *Last Close Contact Date Checkboxes Never in Close ContactDate Last in Restricted Location No Restricted TravelAddress *Address 2 City *State NYCTMANJPAZip *County *UlsterDutchessOrangeRocklandPutnamWestchesterColumbiaGreeneAlbanyOtherGender *MaleFemaleTransgenderOtherDate 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 YORKComments EmailSubmit