UCOP COVID-19 Case and Contact Reporting Form

UCOP COVID-19 Case and Contact Reporting Form

Name*

Email*

What is the best Contact Number our COVID-19 Response Team can reach you at to discuss next steps?*

Please put the best number for our COVID-19 response team to reach you directly.

Phone

Are you a.... *

Employee

Contractor

Visitor

Vendor

Job Position*

If your job position is not listed, please type in your job position into the field.

Select or enter value

Department*

Are you reporting a positive COVID-19 test result or a close contact?*

Positive Test Result

Close Contact

Do you understand that upon completion of this form, you are also required to notify your supervisor and/or manager?*

Yes

How are you feeling overall?

Please describe how you are currently feeling.

What symptoms are you experiencing?*

Please note if a symptom is not listed you can type in additional symptoms you are experiencing

Select or enter value

When was the last time you experienced a fever or chills?*

Please put the date you last experienced a fever or chills while currently testing positive for COVID-19.

What date did your symptoms start?*

Please put the date you started experiencing the onset of symptoms.

When did you receive your test results?*

Were you near a person who tested positive?*

Yes

If you were near a person who became positive, when did they become positive?*

What symptoms did they experience? (Select all that apply)

Select or enter value

When were you exposed?*

Since your close contact exposure, have you been tested for COVID-19?

Yes

Since you indicated above you have taken a COVID-19 test after your close contact exposure, what was the result of the COVID test?

Positive Test Result

Negative Test Result

Invalid Test Result

What is your usual working schedule?

Please indicate your normal working schedule.

Remote

Onsite

Remote and Onsite

When were you last onsite at work?

Please enter the last day you were onsite at UCOP.

When you were last onsite at work, what were your working hours?

For example: 8am-5pm

What building(s) did you visit?

Select or enter value

What floor(s) were you on onsite?

Please specify such as: 5th floor Franklin Building, 3rd Floor UC Path Center, etc.

Where there any onsite common areas you had occupied for a total of 15 minutes when you were last onsite?

Such as breakroom, conference room, kitchen, etc.

Please provide the first and last names of any close contacts you had if you were onsite within 24 hours of your symptom onset. If you did not have any close contacts, please put "N/A".*

Definition of close contact: Someone who was within 6 feet of you for a total of 15 minutes or more over a 24-hour period if you were onsite within 24 hours of your symptom onset.

Where you last on-site for...

Work

Event

Both

Send me a copy of my responses

Privacy Notice|Report Abuse