Patricia Keppler, Personnel & Safety Director
Leana Testani, Assistant Director of Personnel & Safety
City Hall ▪ 38 Hawley Street ▪ Binghamton, NY 13901 ▪(607) 772-7008 ▪www.binghamton-ny.gov
Department of Personnel and Safety
COVID-19 INTAKE EXPOSURE FORM
*Only complete this form if you believe you or a colleague has had direct exposure to COVID-19.
Name: ___________________________________________________________________________
Title/Job Description: ______________________________________________________________
Phone No.: ____________________________________________________________________
I believe myself or a colleague had direct exposure to COVID-19 because:
_____ Direct exposure to individual known to be diagnosed with COVID-19
_____ Direct exposure to individual known to be awaiting results of COVID-19 test
_____ Direct exposure to individual known to be ordered to quarantine due to COVID-19 symptoms
_____ Direct exposure to individual directed to self-quarantine
_____ Direct exposure to individual appearing to display COVID-19 symptoms
Please describe the circumstance and situation of the believed exposure (include date, location).
__________________________________________________________________________________________
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Please list all City of Binghamton colleagues believed to be present or any additional colleagues also relevant to
potential exposure.
__________________________________________________________________________________________
__________________________________________________________________________________________
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Has anyone believed to have been exposed to COVID-19 visited any City of Binghamton sites, offices, etc.? If
yes, when and where?
__________________________________________________________________________________________
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Date Reported to Broome County Health: _____________________________________________
Date Visited Health Provider (incl. telehealth): _____________________________________________
Outcome: ________________________________________________________________________
(Specify: health dept. isolation order, advised by provider to self-quarantine, symptomatic, awaiting test)
*Attach documentation from Health Provider and Broome County Health.
