EMPLOYER REPORTING FORM
Employees/Volunteers Who Test Positive for COVID-19 in Sacramento County
Under California law, Employers are required to report workplace outbreaks to local health departments.
When non-healthcare employers identify 3 or more cases of COVID-19 at a worksite within a 14-day period, they are
required to report this to their local health department within 48 hours.
Confidentiality must be maintained as required by state and federal law and regulations.
Please complete and submit the following form to Sacramento County Public Health (SCPH) for each of your employees
who tests positive for COVID-19. You may be contacted by SCPH if more information is needed.
BUSINESS INFORMATION:
Date of report: ______________Name of reporter: _______________________________________________________
Position/title: ___________________________________________
Business or facility name: _______________________________ Type of business: _______________________________
Business address: ___________________________________________________________________________________
NAICS code: _____________ The North American Industry Classification System (NAICS) code is a standard 6-digit code
used to classify a workplace by industry. To find your business's NAICS code, first click your sector number
, then search
for the specific code for your industry.
Total number of workers at the worksite: _______ (Please include all workers, including temporary or contract workers)
Number of workers with COVID-19: ________
COVID-19 POSITIVE CASE INFORMATION:
Name:____________________________________________Occupation:______________________________________
DOB:____________________________________ Phone:___________________________________________________
E-mail:___________________________________________________________________
Last day at work: _________________________________ Date of positive test :________________________________
