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COVID-19 Suspected Outbreak Form
Questions marked with a
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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
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.
-- Select --
Skilled Nursing Facility (SNF)
Non-SNF licensed and unlicensed caregiving facilities (AL, ALF, RCFE, ARF, ICF, CLHF)
Other residential caregiving facilities including Residential Substance Use, Sober Living, ODR
Residential non-caregiving facilities
Outpatient Facilities or Dialysis Centers (including home health, dental, veterinary and physical therapy offices)
Acute Care Hospitals, Acute Psychiatric Hospitals, Sub-acute, D/P SNFs, and LTC licensed by hospitals
Places of Worship, Recreation and Gym/Fitness
Education (college and university, trade school, K-12 schools, early childhood education, family childcare, preschool, afterschool program, camp, parks and rec, daycare, youth sports)
Persons Experiencing Homelessness (shelter, agency providing housing or services)
First Responders (EMS, Fire and Private Ambulance Providers)
Law Enforcement and Courts (police/sheriff stations, highway patrol, courthouses)
Correctional Facilities (jails, prisons, juvenile probation)
Food facilities (restaurants, take out, bars, grocery stores, any facility that sells, processes or ships food)
Work sites (businesses including but not limited to manufacturing, storage, transport, distribution and/or retail of non-food items, offices, construction, media, and service providers including government, auto, hotels, banks)
Other - PLEASE CONFIRM YOUR FACILITY DOES NOT FIT IN ONE OF THE ABOVE CATEGORIES
Is this report an update to a previous recent report of cases?
Yes
No
Additional Information:
Done
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