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COVID-19 Employee Contact Tracing Report

This form should be completed when an employee has tested positive for COVID-19. The purpose of this form is to document which individuals had close contact with the infected individual. Close contact is defined as being within 6 feet of a person with COVID-19 for at least 15 minutes.

Date of Report*

Answer Required

Reporting Supervisor*

Name of person completing the report.

Answer Required

Name of COVID-19 Positive Employee*

Answer Required

Employee's Position *

teacher, nutrition technician, etc.

Answer Required

Date of Positive Test*

Initial test date, not date that results were received

Answer Required

Last Day of Work*

Answer Required

List the name and date of all individuals that were in close contact with the individual. If there were no close contacts reported, please indicate "none."*

ex. Gina Bennett - 6/30/20

Answer Required

Confirmation Email

Confirmation Email *

Email Required