Mazama COVID Exposure Reporting

Please use this form to report COVID exposure so we can inform others who may have come in contact with you at the Mazamas. Your name will be withheld.

Date of potential exposure

First Day * +

Last Day * +

Where potential contact occurred *

Have you or anyone in your household come down with any of the following symptoms since you participated in your Mazama activity/program? (check all that apply). Include new symptoms only—if you have a chronic runny nose for example, you do not need to count it as a new symptom. *

First Day of Symptoms * +

Have you tested positive for COVID-19 since your were at the MMC or in a Mazama Activity/Program? *

Yes

No

Date Tested * +

Were you in contact with anyone prior to or during your involvement in a Mazama program who has since come down with any of the symptoms listed above? *

Yes

No

First Day of Symptoms * +

Were you in contact with anyone prior to or during your involvement in a Mazama program who has since tested positive for coronavirus? *

Yes

No

Date of Test * +

contact info

Contact Information

Your identity will be kept strictly confidential; but in order to notify other participants who may have come in contact with you, we must know your name so we can identify the activity and other participants who will need to be contacted. We will contact you to talk through additional details, prior to contacting any other participants.

Name *

Email Address *

contact info

Is there anything else you would like to share with us?