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City of Missoula
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Covid-19 Reporting

  1. Employee COVID-19 Reporting Form 1
    For a City of Missoula Employee who has tested positive for COVID-19 or identified as a close contact to complete. Purpose: For the City of Missoula Human Resources to identify, report, and track COVID-19 cases and close contacts within City of Missoula workplaces and employees.
  2. * Required
  3. Enter Phone as 10 numbers only
  4. City or Personal email
  5. First & Last Name
  6. Enter Phone as 10 numbers only
  7. First & Last Name
  8. First & Last Name
  9. City or Personal email will work.
  10. If contacted by MCCHD, what was the reason?
  11. COVID-19 Suspected Symptoms Present (Fever, cough, sore throat, loss of taste, headache, etc.)*
  12. Have you been vaccinated for COVID 19 virus?
  13. If yes, has it been 2 weeks since your last vaccination or one shot of Johnson and Johnson?
  14. Has the employee been at work 2 days before the onset of symptoms?
  15. COVID-19 Test Results (If known)
  16. Dates of Isolation
  17. Leave This Blank:

  18. This field is not part of the form submission.