COVID Positive Employee Questionnaire

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Please answer all the questions below, sign the bottom and click submit.

1. Name *

2. Phone *

3. Date of birth *

YYYY

4. Employee Lawson ID *

5. Employees Manager *

6. Which department do you work in? *

7. Date employee tested *

YYYY

8. Location Employee Tested: *

St. Bernards Employee Health Clinic

Home test

Other

Required

9. Date symptoms first occurred *

YYYY

10. Notify your manager of your positive COVID result.

If your initial COVID test was at home or another clinic/pharmacy, call the Employee Health Clinic (870-207-7350) to notify of the positive COVID test & obtain a follow up appointment for retesting and return to work.

If your initial COVID test was performed by ECH, follow their instruction for retesting and return to work.

You must be cleared by the Employee Health Clinic prior to returning to work.

I understand that I must call the Employee Health Clinic to be cleared before returning to work

Required

11. Positive COVID Results & FMLA

You will need to apply for FMLA for a COVID positive test result. Request FMLA through Consolidated Admin Services (CAS) using the link: https://www.p3.biz/stbernards# . Click on the Family Medical Leave tab and follow the instructions.

You must upload a copy of the positive COVID test result with the leave application. Home tests are not accepted. The leave will automatically be approved and no other paperwork is needed for the leave.

I hereby certify, as attested by typing my name, that all the information I have provided is true and correct, and contain no false statements or representations. Provide NAME & DATE below.

Submit

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