Close Contact with positive COVID-19 case

Use this form to report if you have come into contact with someone who has recently tested positive for COVID-19.

Close contact is defined as being within 6-feet of an individual with COVID-19 for a total of 15-minutes within a 24-hour period.

If you are unvaccinated, please stay home and quarantine until further directions from the Student Health Center or Human Resources.

Individuals who are vaccinated and asymptomatic, or who have tested positive within the last three months, do not need to quarantine. The Student Health Center or Human Resources will be in contact with further directions. Please wear a mask, monitor for symptoms, and continue normal activities.

Name Name First Last
Medaille ID Number
Must be 8 digits. Currently Entered: 0 digits.
College Email
Phone Phone - ### - ### ####
College Affiliation

College Affiliation Student Faculty/Staff
Campus Affiliation

Campus Affiliation Buffalo Rochester N/A (Online)
Do you live in the residence halls?

Do you live in the residence halls? Yes No
Are you affiliated with Medaille College Athletics?

Are you affiliated with Medaille College Athletics? Yes No
Are you fully vaccinated against COVID-19?

Are you fully vaccinated against COVID-19? Yes No
If you have not already provided a copy of your COVID-19 vaccine card, please do so here.

Attach Files
Have you tested positive for COVID-19 within the last 90 days?

Have you tested positive for COVID-19 within the last 90 days? Yes No
If yes, what was the date of your positive test? If yes, what was the date of your positive test? / MM / DD YYYY
Please upload a copy of your positive lab result with your name and date of test.

Attach Files
Attestation of Close Contact

Attestation of Close Contact I attest that I have had close contact with someone who has tested positive for COVID-19. By attesting to this, I understand that Medaille College is required to communicate all information regarding COVID-19 testing and contact tracing to the Erie County and State Health Departments, and is required to verify all positive close contacts.
Please provide name, address, phone number of the individual who tested positive.
Date of last contact with the positive individual listed above Date of last contact with the positive individual listed above / MM / DD YYYY
Please describe your interaction with the person who tested positive. Please include length of contact and whether you were both masked.