BHA COVID-19 Positive Test Reporting Form for OTPs and Residential/Congregate Living Facilities
For accessing the Protocol for the BHA COVID-19 Positive Test Reporting Form please click at the link: https://drive.google.com/file/d/12UAH_uz3zvNiX4fqHNOXl8Kp5DJYScoy/view?usp=sharing

Program Name: *
Location: *
Jurisdiction: *
Type of Program(if BHA licensed, certified, or funded): *
Date of Report: *
MM
/
DD
/
YYYY
Report Completed by: *
Email: *
Telephone: *
Census of program at this site: *
Notifications [include names/contact info & dates for both initial contact & updates for new cases, with any recommendations provided (explain if not implemented)]:
Local Health Department (1st notification): *
LBHA/LAA/CSA (2nd notification): *
Other: *
Actions implemented: *
Number of 𝙨𝙩𝙖𝙛𝙛 initially testing positive within past 14 days: *
Number of 𝙨𝙩𝙖𝙛𝙛 tested in past 14 days: *
Number of 𝙨𝙩𝙖𝙛𝙛 who have been hospitalized in past 14 days: *
Number of any 𝙨𝙩𝙖𝙛𝙛 deaths: *
Number of 𝙥𝙖𝙩𝙞𝙚𝙣𝙩𝙨 initially testing positive in past 14 days: *
Number of 𝙥𝙖𝙩𝙞𝙚𝙣𝙩𝙨 tested in past 14 days: *
Number of 𝙥𝙖𝙩𝙞𝙚𝙣𝙩𝙨 who have been hospitalized in past 14 days: *
Number of any 𝙥𝙖𝙩𝙞𝙚𝙣𝙩𝙨 deaths: *
If additional cases return positive, there are hospitalizations or deaths, or your LHD or LBHA/LAA/CSA has additional recommendations, the form should be updated.
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