COVID-19 Incident Form 

Who completes the form?  

For any suspected illness or exposure, the Direct Manager.



Positive COVID 19 test result*

Do not submit this form. Follow your absenteeism policy.



COVID 19 test Date*
Name of the individual completing this form. *
Home or Contact Number 24/7
I am the
Line of Service of the Individual*
Individual's Bureau/Region*

Employee Information 

Employee Name (Legal Name)*
**Contact for 24/7
(Do not use work phone)
Employee Date of Birth*

Direct Manager Information 

(of the individual)

Direct Manager Name*

Outcome

Exposure Event
Outcome*
Return To Work Date*
5 days after onset of symptoms with
a positive COVID 19 test
Date of exposure:*
Masking of both the exposed
employee and source?*
Respirator use by exposed employee?*
Use of other PPE during exposure?*
Duration of exposure event*
Distance of exposure event
Exposure Source
Who was the source of exposure?*
Was the source person tested for COVID?*
Date of Test: (Source Person)*
COVID PCR, IgM, IgG, Other
Test Results (Source Person)*

Information

Employee Assistance Program is available 24hrs / 7 days # 800-272-2727.

Has the individual consulted with a healthcare provider?
Individual has been tested?
Test Date*
Type of Test*
Result*
Has the individual had a COVID-19 Vaccination?
Type of COVID Vaccine Received
1st Vaccine Date
2nd Vaccine Date
3rd Vaccine Date
In the interval from symptom onset or date of testing, has the individual had high risk contact with:
High risk contact requires all of the following: distance less than 6 ft, longer than 15 minutes p/day without dual masking. If yes, a report on each person should be submitted.
Is the individual experiencing symptoms?

Information

Employee Assistance Program is available 24hrs / 7 days # 800-272-2727.

Symptoms

Symptoms onset date*
Please check all symptoms the exposed individual has experienced during illness:*
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