COVID-19 Reporting Form

This report is about

Staff member that received a positive COVID-19 test resultSymptomatic staff member that has not been testedSymptomatic staff member that is awaiting COVID-19 test resultsNon-symptomatic staff member who has been exposed to someone who has received a positive COVID-19 test result

Staff member was exposed

At workIn the communityAt home

Who is making this report?

SelfSupervisorCo-Worker

Affected Staff Member's Full Name

Primary Role

ClinicalNon-Clinical

Partner Name

Location

Cell Number

Home Number

Work Email Address

Home Address

City

State

Zip Code

County of Residence

Date of Exposure

Please explain how you were exposed:

Has the person received a positive COVID-19 test result?

YesNo

Are you experiencing symptoms?

YesNo

Date of Symptom Onset

Types of Symptoms:

Worksites you have visited in the 48 hours prior to symptom onset?