A	B	C	D	E	F	G	H	I	J	K	L	M	N	O
1	CHILD CARE/SCHOOL/CAMP CLOSE CONTACTS
2	Name of facility:						NOTES:
3	Index case:
4	WDRS number:
5	Date of case investigation/by who:
6	Symptom onset date:
7	Last exposure date:
8	Quarantine through:
9	Director/Principal:
10	Facility phone:
11
12	CHILDREN/YOUTH
13	SHD Only	SHD Only	First Name	Last Name	DOB	Group	Parent Name	Parent Mobile Phone	Parent Email	Address	City	State	Zip	Gender
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44	STAFF
45	SHD Only	SHD Only	First Name	Last Name	DOB	Group	Position	Staff Phone	Staff Email	Address	City	State	Zip	Gender
46
47
48
49
50

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