COVID-19 Incident Report Form
Date of COVID-19 test _______________________________________________________
Estimated Date of COVID-19 Possible Exposure: __________________________________
Name of Employee: _________________________________________________________________
Home Address: _____________________________________________________________________
__________________________________________________________________________________
Phone Numbers: (c) ________________ (h) _____________________ (w) ___________________
Date of Birth: _______________________________ S or U number:
____________________________
Employee Department: _________________________________________________________________
Supervisor: ___________________________________________________________________________
Details of Incident or Exposure:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Has employee been seen by primary physician or at a clinic or hospital? Yes ________No_______
If so, give Date of visit________________________________________
What were the physicians’ recommendations to employee?
_____ Self monitor and continue to report to work
_____ Self-isolation or self-quarantine at home
_____ Hospitalizations, if any
Signature of Employee : ____________________________________ Date: ________________
click to sign
signature
click to edit
![]()
