Complete this form if you or your child had close contact with an individual infected with COVID-19. Upon completion, you will receive a document which may be used as if it was an individual Order for Quarantine issued by the Saratoga County Commissioner of Public Health.

Criteria For Quarantine

Person Completing This Form

Email Address

First Name

Last Name

Individual Being Quarantined

First Name

Last Name

Date of Birth

Phone (if individual is a minor, enter your phone number)

Street Address

City

State

Zip Code

Last Day of Exposure to the positive COVID-19 Person

Does the individual being quarantined:

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

Affirmation

BY CHECKING THIS BOX YOU ARE SWEARING TO THE VERACITY OF THE INFORMATION YOU HAVE PROVIDED ON THE FORM, AND THAT SCPHS IS NOT RESPONSIBLE FOR INCORRECT EMAIL ADDRESSES. YOU ACKNOWLEDGE THAT SCPHS MAY VERIFY THE INFORMATION YOU HAVE PROVIDED, AND MAY CONTACT YOU FOR ADDITIONAL INFORMATION. YOU ALSO ACKNOWLEDGE THE AUTOMATICALLY GENERATED EMAIL RESPONSE AND ATTACHED PDF ORDER GENERATED UPON COMPLETION AND SUBMISSION OF THE FORM ARE NOT ENCRYPTED. YOU FURTHER UNDERSTAND THAT YOU MAY BE ASKED BY YOUR OR YOUR CHILD'S EMPLOYER, SCHOOL OR OTHER ENTITY FOR PROOF OF A NEGATIVE TEST IF THIS RELEASE FROM QUARANTINE IS SOONER THAN 10 DAYS AND BASED ON AN APPROPRIATELY TIMED COVID-19 DIAGNOSTIC TEST.

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