If you test positive for COVID-19, you will get a call from a public health representative to identify any
contacts you have had. This form can help you identify your contacts so you will be ready for the call.
Identify date of your first symptoms
If you have had symptoms, put the date you first felt sick OR if you have had no symptoms
then put your date of testing _____/_____/_____
SUBTRACT 2 DAYS: _____/_____/_____ = YOUR CONTACT TRACING DATE
Who has been in your house with you since your contact tracing date?
Include people who live in your home, and people who may have visited like friends, a babysitter
or anyone else providing in-home services.
NAME OF PERSON DATE LAST IN HOME THEIR PHONE NUMBER
Make a list of what you did each day since your contact tracing date with as much detail as possible.
Include things like hanging out with neighbors, going to work, running errands, appointments, social or recreational
activities outside the house, and if you used public transportation to get there. Use another piece of paper if needed.
Day One: _____/_____/_____ PEOPLE YOU WERE WITH
ACTIVITY LOCATION NAME ADDRESS PHONE NUMBER
Day Two: _____/_____/_____ PEOPLE YOU WERE WITH
ACTIVITY LOCATION NAME ADDRESS PHONE NUMBER
Day Three: _____/_____/_____ PEOPLE YOU WERE WITH
ACTIVITY LOCATION NAME ADDRESS PHONE NUMBER
Day Four: _____/_____/_____ PEOPLE YOU WERE WITH
ACTIVITY LOCATION NAME ADDRESS PHONE NUMBER
