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Covid-19 Reporting
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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.
* Required
Employee's Department
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Employee's First Name
*
Employee's Last Name
*
Employee's Date of Birth (DOB)
*
Employee's Date of Birth (DOB)
Employee's Contact Phone Number
*
Enter Phone as 10 numbers only
Employee's Email Address
City or Personal email
Employee's Supervisor Name
*
First & Last Name
Employee's Supervisor Phone Number
*
Enter Phone as 10 numbers only
Name of Person Completing form (if different than employee him/herself)
First & Last Name
Contact Info of person completing form (if different than employee him/herself)
First & Last Name
Email of person completing form (if different than employee him/herself)
City or Personal email will work.
Have you been contacted by the Missoula City Co. Health Department (MCCHD)?
*
Yes
No
Other
What is the reason for filling out this form?
Identified Close Contact
Tested positive for COVID-19
COVID-19 Suspected Symptoms Present (Fever, cough, sore throat, loss of taste, headache, etc.)
*
Yes
No
Have you been vaccinated for COVID 19 virus?
Yes
No
If yes, have you received a vaccine booster?
Yes
No
Has the employee been at work 2 days before the onset of symptoms?
Yes
No
N/A
What is the last date you worked on a City of Missoula Job Site with other City Employees present?
What is the last date you worked on a City of Missoula Job Site with other City Employees present?
Date Expected COVID-19 Symptoms First Began
Date Expected COVID-19 Symptoms First Began
Date of COVID-19 Test
Date of COVID-19 Test
COVID-19 Test Results (If known)
Positive
Negative
Dates of Isolation
Estimated Date of first day of isolation?
Estimated Date of first day of isolation?
Estimated date of last day of isolation?
Estimated date of last day of isolation?
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