CORONAVIRUS EXPOSURE
QUARANTINE LEAVE REQUEST FORM
Employee: Employee Number:
Work Location: Shift: Department:
Name or Relationship to Individual to Whom Employee was Exposed:
Date of Potential Exposure:
Location of Potential Exposure:
Nature of Potential Exposure:
I can be reached at:
Phone:
Email:
Are you seeking consultation or treatment with a telemedicine or healthcare provider for this potential exposure:
□
Yes
□
No (responding “no” will not disqualify you from the leave of absence)
By signing below, I certify that the above information is true and accurate to the best of my knowledge. I understand that any knowing
misrepresentation of this information will be grounds for discipline, up to and including termination.
Employee Signature (may be typed if submitted via email) Date
Email completed form to Medical@Crown.com. Upon completing this and submitting the form, the employee will be released
to leave work until receiving further instruction.
Received by Supervisor:
Initials
Revision Date: 3/19/2020
Are you Part-time, Probationary, Temporary, or Student/Co-op:
□
Yes
□
No
