Facility Positive Reporting

Facility Contact Name *

Facility Contact Phone Number *

Facility Contact Email Address *

Facility Name *

Facility Type *

Other Facility Type *

Facility Address *

Facility City *

Facility Zip Code *

Positive Name *

Positive Date of Birth *

Month

Day

Year

Positive County of Residence *

School Contact Type *

School Address *

Please provide the address of the school where the case resides

How Does the Positive Case Attend or Work at the School? *

If the Student or Staff Participates in On-Site Sports or Activities, List Them Here

Leave this field blank