• Employee's Name:

  • Employee's Contact Number:

  • Nature of the concern:

  • Employee's Symptoms:

  • When did employee's symptoms begin:

  • Last date of work:

  • Has the employee had a COVID-19 test been conducted

  • Nasal swab?

  • When was test conducted?

  • What was the result of the test?

  • Who have you had close contact with prior to you leaving work?

  • Have you and any of the previously mentioned people had any use of common tools or equipment? (tools, telephone, computer, etc)

  • When will a test be conducted?

  • Is there anyone in the employee's place of residence that has recently tested positive for COVID-19?

  • Please give details of the contact


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