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
Have you tested negative for COVID-19 after your first initial positive COVID-19 test?
Has it been five consecutive days since you first tested positive for COVID-19?
Date of Initial Positive COVID-19 Test Result

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Date of Negative COVID-19 Test Result

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Date of Return to Work

MonthDayYear
2 digit month, 2 digit day, 4 digit year
* 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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