COVID Reporting Form Please fill this out for EACH individual affected by COVID (anyone with symptoms, exposure or positive diagnosis) Please enable JavaScript in your browser to complete this form.County ReportingJohnson City OfficeNew BuildTri-Cities RepairVA DickensonVA JonesvilleVA WiseKY BellKY BreathittKY FloydKY HarlanKY KnottKY MagoffinTN CarterTN Washington/HXPTN JohnsonWV CabellWV ClayWV FayetteWV GreenbrierWV KanawhaWV LoganWV McDowellWV NicholasStaff Person Reporting: *Name of COVID affected individual: *FirstLastAffiliation: *StaffAdult VolunteerYouth Volunteer (under 18)HomeownerCommunity MemberOtherIf other, please explain: *If volunteer, name of group they were with: *Date /Time of exposure or symptom onset: *DateTimeWas this COVID affected Individual: *PositiveNegativeSymptoms- Pending ResultsClose Contact Exposure (No Symptoms)OtherIf other, please explain: *If positive, please list the first and last names of all ASP affiliated individuals this person came in close contact with: (close contact defined as within 6’ for more than 15 minutes in a 24 hour period)Is this individual vaccinated? *YesNoUnknownAction Taken: *Individual temporarily quarantined INSIDE the centerIndividual temporarily isolated AWAY from centerIndividual has gone home and will not return to ASPIndividual does not warrant isolation (Has had exposure but is vaccinated), but has been exposed and will wear a mask around others for 5 daysOtherIf other, please explain: *Other actions being taken or comments about the case? (i.e. did the whole group go home, how is the morale of individual/group, etc.):Email *Please include the email address the COVID hotline should use for follow up.Submit