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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 or who has a confirmed positive COVID-19 test. Submit immediately upon notification by employee; must be same day.

EMPLOYEE INFORMATION

* Employee Name:

* Date of Birth:
(Format XX/XX/XXXX)

* Employee Personal Cell Phone Number:
(format (XXX)XXX-XXXX)

* Job Title:

* Department:

* Supervisor:

TYPE OF REPORT

Check all that apply:

Employee has COVID-19 Symptoms - Complete Section 1 below

Employee has confirmed COVID-19 (positive test) - Complete Section 2 below

1. SYMPTOMS INFORMATION

Date of Symptom Onset:
(Format xx/xx/xxxx)

Date Employee reported symptoms:
(Format xx/xx/xxxx)

Description: (include details such as dates, how notified, etc.)

Symptoms Employee Experienced:
Check all that apply

Fever/Chills

Headache

Fatigue

Loss of taste/smell

Nausea/vomiting

Shortness of breath

Muscle/Body Aches

Congestion or Runny nose

Difficulty Breathing

Cough

Sore throat

Diarrhea

2. POSITIVE TEST INFORMATION

Date test taken:
(Format xx/xx/xxxx)

Date test results received:
(Format xx/xx/xxxx)

Type of test taken:

		Home test
		Clinic test - rapid
		PCR

Employee is:

		Symptomatic
		Asymptomatic

*Reminder: Forward copy of test results to COVID Team immediately

WORKSITE INFORMATION

* Last date employee worked (physically at work):
(Format xx/xx/xxxx)

* Primary worksite location (address):

* Beginning 48 hours prior to symptoms or positive test result, who did the employee come into close contact with at the worksite(s)?

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

* Date Submitted:
(Format xx/xx/xxxx)

* Name and job title of reporting party:

* Reporter's Email address:

* Phone number of reporting party:
(format (XXX)XXX-XXXX)

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

The City of Visalia

220 N. Santa Fe St.
Visalia, CA 93291
Phone: (559) 713-4300
Fax: (559) 713-4803

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