POSITIVE TEST/EXPOSURE REPORT FORM

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POSITIVE TEST/EXPOSURE REPORT FORM

The information gathered in this form is used strictly for contact tracing and will only be shared with those who are required to know. Please talk to your manager if you have any

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* Indicates required question

First Name *

Your answer

Last Name

Your answer

Supervisor's Name

Your answer

Vaccination Status

Unvaccinated

Vaccinated (2 shots plus appropriate waiting time)

Vaccinated and Boosted

Other:

Clear selection

Are you positive or confirmed close contact? *

Positive

Close Contact - with mask

Close contact - no mask

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