COVID-19 Employee Tracking

COVID-19 Employee Tracking

Employee Last Name

Employee First Name

Employee Manager

Symptoms?

Select or enter value

If yes, list symptoms.

Date symptoms reported.

Date excluded from work?

Is it work related?

Select or enter value

Did employee receive a COVID-19 test? Yes or No?

Select or enter value

If yes, list date employee was tested.

What were the test resutls?

Select or enter value

When were the results receved?

If not tested, dr.'s note received?

Select or enter value

Was the positive test reported to the Health Dept.

Select

If test was positive, close contacts?

Select or enter value

If Yes, list dates and types of contact.

Is isolation or quarantine required?

Select or enter value

If yes, list the requirement. For example, 10 day

Select or enter value

If other, specify:

When does the isolation or quarantine end?

When did employee last have symptoms?

Have symptoms improved prior to return to work?

Select or enter value

If other, explain:

What date is the employee cleared to return?

Notes

Send me a copy of my responses

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