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Employee COVID-19 Report

COVID-19 Reporting Form
EMPLOYEE COVID-19 REPORTING FORM
Must be Submitted Immediately

This form must be completed by the designated Department Representative or Supervisor of the impacted employee. Submit this form for any employee who has COVID symptoms, has had a close contact exposure to a COVID-positive person, or who has a confirmed positive COVID-19 test. Submit immediately upon notification by employee; must be same day.

EMPLOYEE INFORMATION






TYPE OF REPORT
Employee has COVID-19 Symptoms - Complete Section 1 belowEmployee was exposed to a COVID-19 positive person - Complete Section 2 belowEmployee has confirmed COVID-19 (positive test) - Complete Section 3 below
1. SYMPTOMS INFORMATION


Fever/ChillsHeadacheFatigueLoss of taste/smell
Nausea/vomitingShortness of breathMuscle/Body Aches
Congestion or Runny noseDifficulty Breathing
CoughSore throatDiarrhea
Other
2. CLOSE CONTACT EXPOSURE INFORMATION
Close Contact = Sharing indoor airspace with COVID positive person for 15 minutes or more in a 24-hour period during infectious period.  Spaces such as offices with floor to ceiling walls are distinct indoor spaces.
3. POSITIVE TEST INFORMATION


Home test
Clinic test - rapid
PCR
Symptomatic
Asymptomatic
*Reminder:  Forward copy of test results to COVID Team immediately

WORKSITE INFORMATION




Close Contact = Sharing indoor airspace with COVID positive person for 15 minutes or more in a 24-hour period during infectious period.  Spaces such as offices with floor to ceiling walls are distinct indoor spaces.

REPORT COMPLETION SIGNATURE




*Reminder:  Submit copies of COVID-19 test results and all related doctor’s notes to COVID Team immediately.
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