Employee Health - Self Reporting
Name
*
First Name
Last Name
Employee Number
*
Department
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Supervisor's Email
*
example@example.com
Date of Positive COVID-19 Test Result
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date of Onset of Symptoms
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date of Return to Work
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
If you have been fever free for 24 hours and you are asymptomatic or mildly symptomatic (with improving symptoms) you may return to work on this date.
Upload a copy of your positive COVID-19 test from your healthcare provider. Home testing is not acceptable documentation.
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