Fillable North Central Health District COVID-19 Positive Employee Report (Georgia North Central Health District)

Fill Online, Printable, Fillable, Blank North Central Health District COVID-19 Positive Employee Report (Georgia North Central Health District) Form

Use Fill to complete blank online GEORGIA NORTH CENTRAL HEALTH DISTRICT pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

North Central Health District COVID-19 Positive Employee Report (Georgia North Central Health District)

On average this form takes 9 minutes to complete

The North Central Health District COVID-19 Positive Employee Report (Georgia North Central Health District) form is 1 page long and contains:

  • 0 signatures
  • 21 check-boxes
  • 28 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Georgia North Central Health District forms online.

BROWSE GEORGIA NORTH CENTRAL HEALTH DISTRICT FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Epidemiology, Community Assessment
& Research Initiatives
201 Second St., Suite 1100
Macon, GA 31201
Phone: 478-751-6303
Fax: 478-751-6099
North Central Health District COVID-19 Positive Employee Report
Employee Information
Last Name: _____________________________ First Name: ______________________ M.I: _________
Date of Birth: ___________________________ Phone Number: __________________________
Date Last Worked: _______________________
Date of COVID-19 Test: ___________________ ☐ Employee not tested
Type of COVID-19 test (PCR, rapid, antibody, etc.): ___________________________________________
Testing location: _______________________________________________________________________
Date symptoms began: _____________________ ☐ Employee not experiencing symptoms
Personal protective equipment used: ☐ None ☐ Cloth face covering ☐ Medical-grade surgical mask
☐ N-95 mask ☐ Face shield ☐ Goggles ☐ Gloves ☐ Tunic ☐ Other: _____________________
Close Contacts
Employees, volunteers, visitors or patients who were less than 6 feet apart for 15 minutes or more, masked or unmasked.
1. Name: __________________________________________________ Phone: ____________________
Has this person had COVID-19 within the past 3 months? ☐ No ☐ Yes
If yes, date of symptoms; if no symptoms, date of positive COVID-19 test: ________________________________
2. Name: __________________________________________________ Phone: ____________________
Has this person had COVID-19 within the past 3 months? ☐ No ☐ Yes
If yes, date of symptoms; if no symptoms, date of positive COVID-19 test: ________________________________
3. Name: __________________________________________________ Phone: ____________________
Has this person had COVID-19 within the past 3 months? ☐ No ☐ Yes
If yes, date of symptoms; if no symptoms, date of positive COVID-19 test: ________________________________
4. Name: __________________________________________________ Phone: ____________________
Has this person had COVID-19 within the past 3 months? ☐ No ☐ Yes
If yes, date of symptoms; if no symptoms, date of positive COVID-19 test: ________________________________
5. Name: __________________________________________________ Phone: ____________________
Has this person had COVID-19 within the past 3 months? ☐ No ☐ Yes
If yes, date of symptoms; if no symptoms, date of positive COVID-19 test: ________________________________
Report date: _______________________ Taken by: _______________________________
Email completed form to nchd.epi@dph.ga.gov
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

North Central Health District COVID-19 Positive Employee Report (Georgia North Central Health District)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 21 April 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document