Employers and Organizations

Contact Tracing
Employers and Organizations
Attention Manager or Director: Please complete a separate form for each positive COVID case you are reporting for your facility. Provide as much info as you can without substantial delay.
Date*

MonthDayYear
Date
Completed by*
1. Business, Location, and Primary Contact Information
Name of Entity*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Hours/Days of Operation
Type of Operation
Site point of contact*
Title or Role
Office Phone*
Please enter a valid phone number.
Alternate Phone

Area CodePhone Number
Email *
*Point of Contact: Personal health information is shared; the business point of contact should be a manager or human resources contact, not a co-worker.
Have you already been in contact with anyone at the Health Department about this possible workplace exposure?
SCCHD Employees Name:
Be phone, Email, Other?
Date of contact

MonthDayYear
Date
2. Employees of staff
Total number of employees/staff employed at site
Past 2 weeks, how many individuals tested COVID-19 positive?
3. COVID-19 Positive Employee
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
City and County of Residence
Personal Phone Number*

Area CodePhone Number
Email
example@example.com
Job Title*
(if applicable) Date individual developed symptoms

MonthDayYear
Date
Date individual was tested*

MonthDayYear
Date
Date individual received positive test result

MonthDayYear
Date
Date organization was notified of positive test result

MonthDayYear
Date
Did individual complete an "at-home" test?*

YesNo
If yes to above question, what date did the individual test positive?

MonthDayYear
Date
Date individual last worked/ or was onsite

MonthDayYear
Date
7. Steps taken in response to being notified about this COVID positive individual(s):
8. Any other information that could be helpful to St. Clair County Health Department:
Recommendations from the St. Clair County Health Department
- Ensure that sick leave policies are flexible and consistent with public health guidance; permits employees to stay home to care for a sick family member, and those employees are aware of these policies. Actively encourage sick employees stay home. https://www.michigan.gov/leo/initiatives/covid-19-workplace-safety
- Monitor employees, volunteers and contractors for acute respiratory illness symptoms (i.e. cough, shortness of breath) upon arrival to facility or become sick during the day. Send symptomatic staff home immediately to follow up with a healthcare provider and/or seek COVID testing. To find a test site visit www.michigan.gov/coronavirus. Employees may return to work if no longer infectious as per CDC, most current guidlines visit https://www.cdc.gov/coronavirus/2019-ncov/index.html
- Upon notification of a COVID positive employee, customer, volunteer, or contractor; the employer should complete a Contact Tracing Worksheet. Review facility policy and procedure on notifying any co-workers, contractors, volunteers, or customers who were identified as a close contact with the COVID positive individual. Submit electronically on www.scchealth.co –or-Secure Fax: 810-985-4340.
- Continue to minimize exposure between healthy employees and ill employees. Put safeguards in place. Assure protocols are followed on all shifts at all times. https://www.michigan.gov/leo/initiatives/covid-19-workplace-safety
- Ensure preventative measures are in place such as signage, masking, hand sanitizer, etc.
Visit www.scchealth.co for information and updates.
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Contact Tracing

Employers and Organizations