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
-
Month
-
Day
Year
Date
Contact Phone Number
-
Area Code
Phone Number
Work Location (select from list)
*
AC Apartment
AJW
All Sites
Burress
Central Office
CF1
CF2
CF3
Cowan
Doby
DP
Durrett
Holbrook
Hollinger
Lowder
Martin
McGee-Hudson
MGS
Morrell
Morrow Valley
PCA
Potting Shed
Remote (working from home)
RWT
Sundries
Starr
Stickney
Tanglewood
Taylor
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
Indicate completion status
Received 1st dose
Received 2nd dose
Received booster
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
Other
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
If yes, what date was the test obtained?
-
Month
-
Day
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?
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
By signing below, I acknowledge that the information I've given is accurate and complete.
Date
*
-
Month
-
Day
Year
Date
Signature
*
Submit
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