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Montgomery County NY - COVID 19 Isolation Affirmation

Click here if you've already completed your affirmation and wish to view your report

Complete this form if you or your child test positive for COVID-19, even if you do not have symptoms. Upon completion, you will receive a document which may be used as if it was an individual Order for Isolation issued by the Montgomery County Director of Public Health.

Person Completing This Form

*Email Address:
*First Name:
*Last Name:

Individual Being Isolated

*First Name:
*Last Name:
*Date of Birth:
*Phone Number:
Format: 555-555-5555
*Street Address:
*City:
*State:
*Zip:
*Specimen Collection Date of Positive Test:
*Symptom Status: I do not have symptoms of COVID-19
I have or had symptoms of COVID-19
If symptoms are/were present - Date of Symptom Onset:
*Does the individual being isolated:Live, work, visit, or provide services to people at congregate living facilities
Attend or work at a K12 school
Attend or work at a Pre-K or Daycare (Licensed or Not Licensed)
Work for a village, town, city, county, state or federal government agency other than law enforcement
Work for a law enforcement or first responder agency
None of the above
If applicable, please enter name of facility, school, or agency referenced above:

*Affirmation

BY CHECKING THIS BOX YOU ARE SWEARING TO THE VERACITY OF THE INFORMATION YOU HAVE PROVIDED ON THE FORM, AND THAT MCPH IS NOT RESPONSIBLE FOR INCORRECT INFORMATION ENTERED. YOU ACKNOWLEDGE THAT MCPH MAY VERIFY THE INFORMATION YOU HAVE PROVIDED, AND MAY CONTACT YOU FOR ADDITIONAL INFORMATION. YOU ALSO ACKNOWLEDGE THAT ANY AUTOMATICALLY GENERATED EMAILS AND REPORTS GENERATED UPON COMPLETION AND SUBMISSION OF THE FORM ARE NOT ENCRYPTED.


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