Covid-19 Notification Report
Use this form to notify GSNCCP
if
someone connected to your troop or service unit is diagnosed with COVID-19,
and has
potentially exposed others during a Girl Scout event or activity. To maintain the affected person's
privacy, do not share health information with others; council staff will notify those potentially exposed in a
manner consistent with healthcare privacy laws. After filling out the document, please email the completed
form to covidreporting@nccoastalpines.org.
Tell us about the person who was diagnosed with COVID-19.
Name Registered Member?
Q
Yes
Q
No
Parent/Guardian's Name
Email
Phone
Address
City
State
Zip
Date of COVID-19 Test
Date of Positive Diagnosis
Tell us about the gathering where they may have exposed others.
Name of Event
Date of Event
Name of Event Venue
Were Venue Staff Present Yes No
Venue Contact Phone Email
Venue Address City State
Zip
List all event attendees. Attach additional pages as necessary
First Name Last Name
Girl
Role at Event
