County of Santa Clara COVID-19 Death Report Form
Complete this form if decedent has ever tested positive for COVID-19.
Send via secure email (coronavirus@phd.sccgov.org) or secure fax (408-224-7046).
Fields in red with an asterisk (*) are mandatory. Please submit this form within 24 hours of death.
For instructions on completing this form, go to: www.sccphd.org/covidproviders; click on "Provider
Responsibilities and Guidance" page and then on "Reporting COVID-19 Deaths" in the Table of Contents.
(If additional help is needed, please contact 408-885-4214 option 3 – Provider Intake)
COUNTY OF SANTA CLARA PUBLIC HEALTH DEPARTMENT [V6] – rev. 01.28.21
*Today’s Date:
*Reporting Facility Name:
☐ Home ☐ Congregate Setting*
☐ ED* ☐ Hospital* ☐ Hospice*
*Name of Patient:
*DOB:
*Has the Medical Examiner already been notified? ☐ Yes ☐ No*
*If no, please do so immediately by calling 408-793-1900 ext. 2.
☐ Positive PCR Test
☐ Positive Antigen Test
If the decedent tested positive for COVID-19, please send their PCR or antigen test result with this Death Report Form.
Do not report antibody test results because they are not adequate for diagnosing COVID-19.
Date of specimen collection:
Date of specimen collection:
*Patient Address:
Type of housing:
Facility Name (if applicable):
Phone#:
Name:
Relationship:
Additional Notes
*Did decedent have a:
*Location of Death:
*Date of Death:
Next of Kin
COVID-19 Lab Results
Medical Examiner Notification
Patient Address
*Location Name (if different from Reporting Facility):
