COVID-19 Incident Report
Use this form to notify GSBDC if anyone connected to your troop or service unit is diagnosed with Covid-19, and has potentially exposed others during a Girl Scout event or activity.
Tell Us about the person who was diagnosed with COVID-19:
Tell Us about the person who was diagnosed with COVID-19:
Name:
Registered Member?
Is this person:
Parent/Guardian's Name:
Email:
Phone:
Address:
City:
State:
Zip:
Date of COVID-19 Test:
Date of Positive Diagnosis:
Tell us about the gathering where they may have exposed others:
Tell us about the gathering where they may have exposed others:
Name of Event: (Ex: troop meeting)
Date of Event:
Name of Event Venue:
Has the venue been contacted?
Was the space cleaned afterwards?
Venue Contact:
Phone
Email
Venue Address
City
State
Zip
List all event attendees.
List all event attendees.
Girl Member Names
Volunteer Names
Parent/Guardian Names
Other
Tell us about yourself?
Tell us about yourself?
Name-
Registered Member-
What is your Girl Scout Role?
Email-
Phone Number-
Address-
City-
State-
Zip-
Is there anything else to add?
*
Send me a copy of my responses
Submit
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