This form must be used to gather information from an employee who self reports having tested positive for COVID 19 and/or exposure to COVID 19.

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

This form must be completed by the Direct Supervisor.

1. When did you start to experience and/or become exposed to COVID 19 related symptoms as reflected in the Employee COVID 19 Addendum to Employee Handbook? *

YYYY

2. Are you aware that if you report to work with COVID 19 related symptoms, it is a policy violation? *

Yes

3. Have you consistently worn Personal Protective Equipment (PPE)? If so, what (e.g., gloves, mask, shield, head covering)? *

4. Have you been in contact with anyone for more than 15 minutes and closer than 3 - 6 ft apart? If yes, specifically what students, customers, vendors and/or staff members? *

5. When were you last physically on campus/at work? *

YYYY

6. Did you review the Employee COVID 19 Addendum to Employee Handbook? *

Yes

I do not know.

Name of person completing the form

Who are you interviewing?

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of buildingnb.com. Report Abuse

Forms