Request for Quarantine Form – Ulster County COVID-19 Information

First Name *

Middle Initial

Last Name *

Suffix

Email *

Gender *

Exposure Date *

Expected End of Quarantine *

Close Contact

I was in close contact to a person who has tested positive for COVID-19

Last Close Contact Date

Outside NY

I have been outside of New York State since 06/25/2020

Date Last in Out of State

Address *

Address 2

City *

State

Zip *

Date of Birth *

Please fill out the complete year

Home Phone

Cell Phone

Today's Date

Certify1 *

I certify that it has been at least 10 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 or visit out of state, I have been symptom free from: fever, cough, shortness of breath and any other respiratory distress without the use of fever reducing medications.

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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