Provider COVID 19 Exposure Form

Provider Name*

Provider ID Number*

Number of Individuals Exposed to COVID 19*

Age Group Exposed to COVID-19*

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Closure Date

Reopen Date

File Upload

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Client Confirmation*

By checking this box, I certify that the information I have provided is true and correct. I certify that I have not omitted or misrepresented any information required for eligibility for the Mississippi Child Care Payment Program.

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