GHA Autism Supports Employee Illness and COVID Exposure Reporting Form

GHA Autism Supports Employee Illness and COVID Exposure Reporting Form

For the health and safety of our community & those we serve, declaration of illness is required. Be sure that the information below is accurate and complete. Please get immediate medical attention if you have any of the COVID-19 signs.
First Name*
Last Name*
Date of Birth

MonthDay Year
Date
Contact Phone Number

Area Code Phone Number
Work Location (select from list)*
Last Date Worked

MonthDay Year
Date
*Failure to answer questions accurately/honestly will result in disciplinary action- (including possible termination)
Vaccinated for COVID-19?

YesNo
Indicate completion status

Received 1st doseReceived 2nd doseReceived booster
In the past 10 days, have you been around anyone sick or that has been told they have COVID?

NoYes
If Yes to the question above, who/when?
Currently (today) or in the last 10 days, have you had ANY of the following symptoms?

Allergy symptomsCold symptomsFever or feeling feverish (Chills or sweating)Headache or Sinus pain/pressureCongestion or Runny NoseCoughShortness of breath or trouble breathingChest pain or Chest tightnessMuscle or Body achesSore ThroatNausea or VomitingDiarrheaStomach pain/crampingFatigue (being more tired than normal)Loss of Taste or Loss of Smell
Date your symptom(s) started

MonthDay Year
Date
Have you been seen by a provider for your illness?

YesNoAppt has been scheduled
If yes, what date were you seen?

MonthDay Year
Date
Was a COVID test obtained?

YesNo
If yes, what date was the test obtained?

MonthDay Year
Date
What type of COVID test?

Rapid Test (results within 2 hours)Send Out Test (results 24-72 hours)
Were the results Positive or Negative?

NegativePositiveResults Pending
Did you receive discharge paperwork and/or a work release note?

YesNoN/A Did not see provider
If yes, what is your marked return to work date?

MonthDay Year
Date
By signing below, I acknowledge that the information I've given is accurate and complete.
Date*

MonthDay Year
Date
Signature*

Clear
Should be Empty:

GHA Autism Supports Employee Illness and COVID Exposure Reporting Form

*Failure to answer questions accurately/honestly will result in disciplinary action- (including possible termination)