Business COVID-19 Report

COVID 19 Business Report

Please complete this form to make a report of an employee with who have tested positive for COVID-19.
Name of Business or Workplace *
Business or Workplace Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Contact Name for Business or Workplace *

First Name Last Name
Contact Phone Number *

Area Code Phone Number
Contact Email
example@example.com

Employee 1
Name of the Employee

First Name Last Name
Date of Birth (if known/available)

Month Day Year
Date
Phone Number for the Employee

Area Code Phone Number
Date their symptoms started (if they have symptoms)

Month Day Year
Date
Date they were last in the facility or workplace

Month Day Year
Date
Are there additional employees at this workplace who are tested positive for COVID?

Yes No

Employee 2
Name of the Employee

First Name Last Name
Date of Birth (if known/available)

Month Day Year
Date
Phone Number for the Employee

Area Code Phone Number
Date their symptoms started (if they have symptoms)

Month Day Year
Date
Date they were last in the facility or workplace

Month Day Year
Date
Are there additional employees at this workplace who are tested positive for COVID?

Yes No

Employee 3
Name of the Employee

First Name Last Name
Date of Birth (if known/available)

Month Day Year
Date
Phone Number for the Employee

Area Code Phone Number
Date their symptoms started (if they have symptoms)

Month Day Year
Date
Date they were last in the facility or workplace

Month Day Year
Date
Are there additional employees at this workplace who are tested positive for COVID?

Yes No

Employee 4
Name of the Employee

First Name Last Name
Date of Birth (if known/available)

Month Day Year
Date
Phone Number for the Employee

Area Code Phone Number
Date their symptoms started (if they have symptoms)

Month Day Year
Date
Date they were last in the facility or workplace

Month Day Year
Date
Are there additional employees at this workplace who are tested positive for COVID?

Yes No

Employee 5
Name of the Employee

First Name Last Name
Date of Birth (if known/available)

Month Day Year
Date
Phone Number for the Employee

Area Code Phone Number
Date their symptoms started (if they have symptoms)

Month Day Year
Date
Date they were last in the facility or workplace

Month Day Year
Date
If you have additional employees who have COVID-19 to report to us, please complete this form again.

Close Contacts
If you identify that the ill employee(s) had any close contacts in the workplace, please complete the quarantine list found on our website to share close contacts of positive employees with public health.

Someone with COVID is infectious for 2 days before they started to have symptoms. For those who test positive but don't have symptoms, they are infectious for 2 days before the date they were tested.

Close contacts are anyone who was within 6 feet of the person with COVID for 15 or more minutes while the person was infectious. This would include employees who had short interactions that total 15 or more minutes within a 24 hour period.

Anyone on this list should be excluded from work for 14 days from the date they were last exposed to the person who has COVID. A negative test result does not end the quarantine period early.
Were any close contacts of the employee(s) who have COVID-19 identified?

Yes No
Please upload your Quarantine List here for any close contacts who were identified.

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COVID 19 Business Report