100%

COVID-19 Suspected Outbreak Form

Questions marked with a * are required

This portal is for reporting of a suspected outbreak by business owners/managers, administrators and supervisors for facilities in Calaveras County. Please be sure to provide as much information as possible. A separate report needs to be submitted for each facility/site with COVID-19 cases.

Facility/Site Information

Facility/Site Name:

Facility/Site Street Address:

Facility/Site City:

Facility/Site Zip Code:

Facility/Site Phone Number:

Point of Contact Information

First Name

Last Name

Phone (ten digit U.S. phone number)

Phone extension

Email Address

Role at Facility/Site

Additional Information

What type of facility/site are you reporting for? Please review all categories and choose the best fit.

Is this report an update to a previous recent report of cases?

Yes

Additional Information: