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BHA COVID-19 Positive Test Reporting Form for Β Residential/Congregate Living Facilities
ONLY PROVIDERS WITH A POSITIVE TEST SHOULD COMPLETE THIS FORM. THIS IS NOT A SURVEY ABOUT WHETHER OR NOT YOU HAVE ANY POSITIVE TESTS.
For accessing the Protocol for the BHA COVID-19 Positive Test Reporting Form please click at the link:
https://health.maryland.gov/bha/Documents/Covid%20Reporting%20Form%20Protocol%20-%20v2.pdf
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* Required
Program Name:
*
Your answer
Location:
*
Your answer
Jurisdiction:
*
Choose
Allegany County
Anne Arundel County
Baltimore City
Baltimore County
Calvert County
Caroline County
Carroll County
Cecil County
Charles County
Dorchester County
Frederick County
Garrett County
Harford County
Howard County
Kent County
Montgomery County
Prince George's County
Queen Anne's County
Somerset County
St. Mary's County
Talbot County
Washington County
Wicomico County
Worcester County
Type of Program(if BHA licensed, certified, or funded):
*
RRP
Group Home
Level 3.1
Level 3.3
Level 3.5
Level 3.7
Recovery Residence
Residential Crisis
Other:
Date of Report:
*
MM
/
DD
/
YYYY
Report Completed by:
*
Your answer
Email:
*
Your answer
Telephone:
*
Your answer
Census of program at this site:
*
Your answer
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):
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Your answer
LBHA/LAA/CSA (2nd notification):
*
Your answer
Other:
*
Your answer
Actions implemented:
*
Your answer
Number of π¨π©πππ initially testing positive within past 14 days:
*
Your answer
Number of π¨π©πππ tested in past 14 days:
*
Your answer
Number of π¨π©πππ who have been hospitalized in past 14 days:
*
Your answer
Number of any π¨π©πππ deaths:
*
Your answer
Number of π₯ππ©πππ£π©π¨ initially testing positive in past 14 days:
*
Your answer
Number of π₯ππ©πππ£π©π¨ tested in past 14 days:
*
Your answer
Number of π₯ππ©πππ£π©π¨ who have been hospitalized in past 14 days:
*
Your answer
Number of any π₯ππ©πππ£π©π¨ deaths:
*
Your answer
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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