Employee COVID-19 Reporting Form

Date: * +

Employee Name: *

Employee ID:

DOB: *

Email: *

Campus/ Department: *

Job Title: *

Home Address & County: *

Phone # (where you can be reached): *

1st day of symptoms: +

1st day out of work: +

Do you have symptoms of COVID-19? *

Yes

Symptoms:

How were you exposed?

Where were you tested?

Date Tested: +

Test Results:

Have you been exposed to someone who has tested positive for COVID-19? *

Yes

If yes, what is your relationship?

If yes, when was their first day of symptoms or diagnosis? +

Please describe contact:

Please answer the questions below for each person you have had direct contact with for less than 6 feet and for 15 minutes or more (accumulatively). Only submit information if the contact was an NBISD employee(s) and/or student(s) since symptoms began or diagnosis was confirmed.

*Please complete a new form if you have more than 10 contacts to report.

Name (First and Last):

Date of Contact: +