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:

Name:

Registered Member?

Select or enter value

Is this person:

Select or enter value

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:

Name of Event: (Ex: troop meeting)

Date of Event:

Name of Event Venue:

Has the venue been contacted?

Select or enter value

Was the space cleaned afterwards?

Select or enter value

Venue Contact:

Phone

Venue Address

City

State

Zip

List all event attendees.

Girl Member Names

Volunteer Names

Parent/Guardian Names

Other

Tell us about yourself?

Name-

Registered Member-

Select or enter value

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

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