GHA Autism Supports Employee Illness Reporting Form

GHA Autism Supports Employee Illness 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

Month Day Year
Date
Contact Phone Number

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

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

Yes No Received 1st dose
In the past 10 days, have you been around anyone sick or that has been told they have COVID?

No Yes
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 symptoms Cold symptoms Fever or feeling feverish (Chills or sweating) Headache or Sinus pain/pressure Congestion or Runny Nose Cough Shortness of breath or trouble breathing Chest pain or Chest tightness Muscle or Body aches Sore Throat Nausea or Vomiting Diarrhea Stomach pain/cramping Fatigue (being more tired than normal) Loss of Taste or Loss of Smell
Date your symptom(s) started

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

Yes No Appt has been scheduled
If yes, what date were you seen?

Month Day Year
Date
Was a COVID test obtained?

Yes No
What type of COVID test?

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

Negative Positive Results Pending
Did you receive discharge paperwork and/or a work release note?

Yes No N/A Did not see provider
If yes, what is your marked return to work date?

Month Day Year
Date
If you did not see a provider, did you obtain a COVID test at a testing location?

Yes No N/A (went to a provider for test)
Were the results Positive or Negative?

Negative Positive Results Pending
Think of anyone you have been around while at work since 2 days before your symptoms started OR 2 days before you were tested for COVID. Make a list of these employees or Individuals here--
By signing below, I acknowledge that the information I've given is accurate and complete.
Date *

Month Day Year
Date
Signature *

Clear
Should be Empty:

GHA Autism Supports Employee Illness Reporting Form

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