COVID-19 • Site Reporting

Please complete one form for each unit or employee that you are reporting.

Choose the type of report.

Indicate the number of staff members affected

Indicate the number of site staff hospitalized

Select the appropriate event type for the unit or employee you're reporting on. Please select one.

Enter the number of household members residing in the unit.

When did you learn of this specific event?

How many residents in the unit are hospitalized?

Your name here please.

Please attach 1.) Notice to the residents informing the community of the confirmed case; 2.) Management's response to prevent the spread of the virus.

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