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* 1. What type of organization is submitting this report?

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* 2. Please provide the name of the organization reporting

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* 4. We were made aware of the positive case in our organization by:

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* 5. The positive COVID-19 case was related to a

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* 6. The individual was participating in the following age group:

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* 7. Date positive case reported to your organization (MM/DD/YYYY)

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* 8. How many individuals in your organization experienced a 14-day cohort break as a result of the positive COVID-19 test result?  Please enter '0' if you do not know.

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