Interaction History Form
People who have tested positive for COVID-19 can submit this form and help us protect the people that they have contacted with.
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Where did you last go public?
When did you go?
-
Month
-
Day
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
What is the address of that place?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Additional information
List of I have contacted with
*
Submit
Should be Empty: