Positive CoVID-19 Employee Reporting

Positive CoVID-19 Employee Reporting

Please complete the form and upload your CoVID-19 results (home test or lab results). If you have any questions or concerns, please contact Risk Management at (281) 498-8110 ext. 29150 or riskmgnt@aliefisd.net. If you need to report a student case please go to https://form.jotform.com/riskmgnt/studentreporting
Today's Date

MonthDayYear
Are you reporting test results for?*

Employee
Are you fully vaccinated (2 shots with Pfizer-BioNTech/Moderna or 1 shot Johnson & Johnson’s Janssen) for more than 14 days?*

YesNo
Is this a 2nd positive reporting within 14 days?*

YesNo
Name*

First NameLast Name
Employee ID*
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Position/Title*
Campus/Dept*
Principal/Department Supervisor*

Employee CoVID-19 Reporting
What are the results of your CoVID-19 test? DO NOT REPORT NEGATIVE RESULTS.*

Positive
When did you received your CoVID-19 test results?*

MonthDayYear
Date
Collection Date of CoVID-19 test*

MonthDayYear
Date
Any CoVID-19 symptoms?*

YesNo
When did you begin experiencing CoVID-19 symptoms?

MonthDayYear
Upload CoVID-19 Results*

Home test or lab results accepted
Cancelof
Possible return to work date

MonthDayYear

Contact Tracking Information
Are there any adults/children in your home that attend Alief schools or work at an Alief school/department?*

YesNo
If yes, please give name of adult/children and their locations within Alief
When was your last day on-site in Alief ISD?*

MonthDayYear
Date
Close contact: less than 6ft for more than 15 minutes over the course of a 24 hour period.

Contact Tracing Date: How to figure out your contact tracing date: If you have had symptoms, put the date you first felt sick OR if you have had no symptoms then put your date of testing _____/_____/_____ SUBTRACT 2 DAYS: _____/_____/_____ = YOUR CONTACT TRACING DATE
Have you been in contact with any staff within your contact tracing date?*

YesNo
If yes, please list staff members that fit the close contact rule.
Have you been in contact with any students within your contact tracing date?*

YesNo
If yes, please list students/class taught that fit the close contact rule.
Have you received approval from your supervisor to work remotely and/or working remotely?*

YesNo

Absence Information
You're required to work remotely unless one or more of the following. Please select all that applies.*

You (not household member) tested positive and feel illYour job duties don’t accommodate remote workNONE APPLY
How do you want your workdays covered?*

Personal Local and/or State DaysFFCRA (district will cover workdays within the initial quarantine, not to exceed 5 days)N/A
First Workday out due to CoVID*

MonthDayYear

Risk Mgnt must receive a negative test result for you and/or your household member in order to clear you to return.*

I agree
Should be Empty: