Onondaga County Health Department
J. Ryan McMahon II, County Executive
Indu Gupta, MD, MPH, Commissioner of Health
John H. Mulroy Civic Center · 421 Montgomery Street, Syracuse, NY 13202
Phone 315.435.3155 · Fax 315.435.5720
SELF-ATTESTATION: AFFIRMATION OF QUARANTINE
(Complete one form for each person)
Complete this form if you or your child:
1. Have been identified as a close contact to a COVID-19 positive person during their contagious period, and
2. Was not fully vaccinated at the time of exposure to a COVID-19 positive person during their contagious
period, and
3. Have been in quarantine.
I, (print name) ______________________________, do hereby affirm that I or my child quarantined from (date)
_________________ through (date) _______________ consistent with guidance issued by the New York State
Department of Health (NYSDOH) and Centers for Disease Control and Prevention (CDC). As per NYSDOH and CDC
guidance, I or my child was identified as a close contact to a COVID-19 positive person during their contagious
period and was not fully vaccinated at the time of exposure. I or my child quarantined for at least five (5) days
(where day zero is the last day of exposure) and have:
1. Remained asymptomatic during the five (5) days OR
2. Developed symptoms but tested negative on a COVID-19 antigen or PCR test.
I understand that a well-fitting mask should be worn around others for 10 days following the date of exposure.
Name of Person in Quarantine: ________________________________________________________________
Date of Birth of Person in Quarantine: ___________________________________________________________
Last Day of Exposure to the COVID-19 Positive Person: _____________________________________________
Affirmed under penalties of perjury by me on (today’s date) ___________________________.
________________________________________
(SIGNATURE)
PLEASE NOTE: YOUR SIGNATURE DOES NOT HAVE TO BE WITNESSED BY A NOTARY PUBLIC; YOU ARE AFFIRMING
TO THE VERACITY OF THE INFORMATION YOU HAVE PROVIDED ON THE FORM.
If completed fully and accurately, based solely on such provided information which I accept as fact, I, Indu
Gupta, Commissioner, Onondaga County Health Department, do hereby find that the affirming individual herein
has met the criteria for quarantine if the date this form is affirmed is more than required number of days (as
consistent with the above requirements) from the listed quarantine period onset date.
Indu Gupta MD, MPH
Commissioner of Health
This form may be used for Quarantine Release or for New York Paid Family Leave COVID-19 claims as if it was an individual
Order for Isolation issued by the Onondaga County Health Department Commissioner of Health.
Updated 1/6/2022
