Employers and Organizations

Attention Manager or Director: Please complete a separate form for each positive COVID case you are reporting for your facility. Provide as much info as you can without substantial delay.

Date*

Date

Completed by*

1. Business, Location, and Primary Contact Information

Name of Entity*

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Hours/Days of Operation

Type of Operation

Site point of contact*

Title or Role

Office Phone*

Please enter a valid phone number.

Alternate Phone

Area CodePhone Number

Email *

*Point of Contact: Personal health information is shared; the business point of contact should be a manager or human resources contact, not a co-worker.

Have you already been in contact with anyone at the Health Department about this possible workplace exposure?

SCCHD Employees Name:

Be phone, Email, Other?

Date of contact

Date

2. Employees of staff

Total number of employees/staff employed at site

Past 2 weeks, how many individuals tested COVID-19 positive?

3. COVID-19 Positive Employee

Name*

First NameLast Name

Date of Birth*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

City and County of Residence

Personal Phone Number*

Area CodePhone Number

Email

example@example.com

Job Title*

(if applicable) Date individual developed symptoms

Date

Date individual was tested*

Date

Date individual received positive test result

Date

Date organization was notified of positive test result

Date

Did individual complete an "at-home" test?*

YesNo

If yes to above question, what date did the individual test positive?

Date

Date individual last worked/ or was onsite

Date

7. Steps taken in response to being notified about this COVID positive individual(s):

8. Any other information that could be helpful to St. Clair County Health Department:

Recommendations from the St. Clair County Health Department

• Ensure that sick leave policies are flexible and consistent with public health guidance.

• Monitor employees, volunteers, and contractors for acute respiratory illness symptoms (i.e. cough, shortness of breath) upon arrival to the facility or during the day. Send symptomatic staff home immediately to follow up with a healthcare provider and/or seek testing for respiratory illness.

• Upon notification of a COVID-19 positive employee, customer, volunteer, or contractor; the employer should complete this Jotform. A copy of the positive test result should also be faxed to SCCHD at 810-987-3062.

• Ensure preventative measures are in place such as signage, masking, hand sanitizer, etc.

Visit www.scchealth.co for information and updates.

Contact Tracing

Employers and Organizations