BOS COVID-19 Report

• Conducted on

  Date

• Prepared by

• Location
  Address

• This COVID-19 Report is for the benefit of every BOS Solutions employee and the personnel we may work in proximity of during the execution of our daily work activities. The faster we can get the details of a situation the quicker we can act to protect everyone involved and get the assistance needed to “Stop The Spread!”

Report

• INITIAL REPORT: Possible COVID-19 Exposure Concern

  Select I have COVID-19 symptoms Someone on my site has COVID-19 symptoms Someone on my site was exposed to COVID-19 Someone on my site tested positive for COVID-19 Other

  • I have COVID-19 symptoms
  • Someone on my site has COVID-19 symptoms
  • Someone on my site was exposed to COVID-19
  • Someone on my site tested positive for COVID-19
  • Other

I have COVID-19 symptoms

• Select all symptoms you are experiencing

  Select Fever Sore throat Cough New shortness of breath Other

  • Fever
  • Sore throat
  • Cough
  • New shortness of breath
  • Other
Please enter your temperature here

• Please provide details and a description of your symptoms

• Have you been tested for COVID-19?

  Yes

  No

• Was the COVID-19 test positive or negative?

  Positive for COVID-19

  Negative for COVID-19

  Results not returned/unknown

• If known what was the date of the positive test?

  Date

Someone on my site has COVID-19 symptoms

• Select all symptoms you observed in the individual of concern

  Select Fever Sore throat Cough New shortness of breath Other

  • Fever
  • Sore throat
  • Cough
  • New shortness of breath
  • Other
Please record their temperature (if it was voluntarily shared with you)

• Please describe any symptoms you observed in detail

• Has the individual with suspected symptoms been tested for COVID-19?

  Yes

  No

  Unknown

• Was the COVID-19 test positive or negative?

  Positive for COVID-19

  Negative for COVID-19

  Results not returned/unknown

• If known, what was the date of the positive test?

  Date

Someone on my site was exposed to COVID-19

• Where was the individual exposed?

  Select Home Work Travel Other

  • Home
  • Work
  • Travel
  • Other

• Describe where the individual was exposed

• What was the date of exposure?

  Date

• Has the exposed individual been tested for Covid-19?

  Yes

  No

  Unknown

• What was the result of the Covid-19 test?

  Positive for COVID-19

  Negative for COVID-19

  Results not returned/unknown

• If known what was the date of the positive test?

  Date

Someone on my site tested positive for COVID-19

• Date of positive test

  Date

• Has the individual sought medical advice from a medical provider?

  Yes

  No

• What actions are currently being taken on-site to prevent the spread of COVID-19?

  Select Quarantine CDC recommendations (social distancing, masks, etc) No specific actions being taken Other

  • Quarantine
  • CDC recommendations (social distancing, masks, etc)
  • No specific actions being taken
  • Other

• Date the individual started the quarantine

  Date

• Have you come within 6 feet of the individual?

  Yes

  No

Other

• Please provide details of your COVID-19 exposure concerns

Additional Comments/Details/Questions and Contact Information

• Additional Comments/Details/Questions

• Your Phone Number

• Your Email Address

• Site Supervisor/Company Man's Name

• Site Supervisor/Company Man's Phone Number

• MANDATORY: Click the paperclip to the right and assign an Action Item to your Immediate Supervisor for "Follow up on COVID-19 Report"

• I acknowledge this information is submitted voluntarily to the COVID-19 Response Team for the purpose of tracking, evaluation and remediation. I further recognize that information provided will be held as confidential as possible. I accept that in some instances, the information provided may require action by the COVID-19 Response Team to ensure the safety and health of myself, my coworkers, and customers.

  I ACCEPT