Employee Incident Form

Date of COVID 19 Test

Estimated Date of COVID-19 Possible Exposure:

First Name

Last Name

Home Address

Contact Number:

Home Number:

Date of Birth

U Number

Employee Department

Supervisor

Details of Incident or Exposure

Has employee been seen by primary physician or at a clinic or hospital?

YES

If so, give date of visit

What were the physicians’ recommendations to you?

Self-monitoring and continue to report to work

Self-isolation and self-quarantine at home

Hospitalization(s), if any

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