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City of Missoula
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Close Contact COVID-19 Reporting Form 3

  1. For the Contact Tracer to notify and report on City of Missoula Case Close Contacts.
    Purpose: To identify, report, and track COVID-19 cases and close contacts within City of Missoula workplaces.
  2. * Required
  3. Enter Phone as 10 numbers only
  4. City or Personal email
  5. First & Last Name
  6. Enter Phone as 10 numbers only
  7. First & Last Name
  8. Phone Number
  9. City or Personal email will work.
  10. Close Contact Employee COVID Quarantine Determination
  11. Has the close contact CC been contacted by the Missoula Co. Health Department?*
  12. Does the CC have COVID-19 Suspected Symptoms Present (Fever, cough, sore throat, loss of taste, headache, etc.)*
  13. Have you been vaccinated for COVID 19 virus?
  14. If yes, has it been 2 weeks since your last vaccination or one shot of Johnson and Johnson?
  15. Dates of Quarantine
  16. Leave This Blank:

  17. This field is not part of the form submission.