COVID-19 Related Letters

Excusal From Work/School Request

You can use this form to request an excusal from work/school letter.

Required fields are marked with an asterisk * and must be completed.

Date of Potential Exposure: *

First Name: *

M.I.:

Last Name: *

Address: *

City: *

State: *

Zip: *

Phone Number 1: *

Phone Number 2:

Email Address: *

Confirm Email Address: *

I certify that I have not tested positive for COVID-19.

Yes

I certify that I was in close contact (within 6 feet for more than 10 minutes) with someone who tested positive for COVID-19, or with someone who had symptoms of COVID-19 and was unable to get a confirmatory test.

Yes

By certifying the answers above, I swear or affirm that the answers I have provided above are true to the best of my knowledge. I understand that if I have knowingly made a false statement herein, I may be subject to prosecution under N.Y. Penal Law § 210.45.

I consent to electronic delivery of a release from isolation letter from the Suffolk County Department of Health. I understand that the letter will reference COVID-19, and contain personally identifiable information as that is defined under the Health Insurance Portability and Accountability Act (HIPAA). I also understand that electronic mail is not a secure form of communication. By checking this box, I release the County of Suffolk from any liability that might arise from transmission of a release from quarantine letter through electronic means to the email address listed above.