Staff Mandatory Reporting Form: COVID-19 Illness/Exposure/Testing Reporting Form

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NOTE: This is NOT the DAILY building entry form. Staff is NO LONGER REQUIRED to complete the building entry form.

This COVID-19 form is intended ONLY for staff experiencing symptoms of COVID-19, who have been exposed to a confirmed positive case of COVID-19, or who are testing for COVID-19. Enter the below information following the employee's self-report.

Email *

Employee Name *

Date of Birth *

YYYY

Employee School/Department *

Employee Telephone Number *

Please use format "XXX-XXX-XXXX"

Employee Position

Supervisor

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