Employee Health - COVID-19 Retest

Employee Health - COVID-19 Retest
Name*

First NameLast Name
Employee Number*
Department*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Supervisor's Email*
example@example.com
YesNo
YesNo
Date of Initial Positive COVID-19 Test Result*

MonthDayYear
Date of Negative COVID-19 Test Result*

MonthDayYear
Date of Return to Work

MonthDayYear
* If you are moderately or severely immunocompromised, a return to work notice will be required from your primary care physician.
Upload a copy of your negative COVID-19 test from your healthcare provider. Home testing is not acceptable documentation.

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