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2. 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.
4. * Required
6. Employee's Department*
   -- Select One --Animal ControlCemeteryCity AttorneyCity ClerkDevelopment ServicesEnvironmental HealthFinancial ServicesFire DepartmentIT/GIS DepartmentHealth DepartmentHousing and Community DevelopmentHuman ResourcesMissoula Redevelopment AgencyMunicipal CourtParking CommissionParks & RecreationPolice DepartmentPublic WorksOther
8. Employee's First Name*
9. Employee's Last Name*
11. Employee's Date of Birth (DOB)*
    Employee's Date of Birth (DOB)
13. Employee's Contact Phone Number*
    Enter Phone as 10 numbers only
15. Employee's Email Address
    City or Personal email
17. Employee's Supervisor Name*
    First & Last Name
19. Employee's Supervisor Phone Number*
    Enter Phone as 10 numbers only
21. Name of Person Completing form (if different than employee him/herself)
    First & Last Name
23. Contact Info of person completing form (if different than employee him/herself)
    First & Last Name
25. Email of person completing form (if different than employee him/herself)
    City or Personal email will work.
27. Have you been contacted by the Missoula City Co. Health Department (MCCHD)?*

    1. Yes
    2. No
    3. Other
29. What is the reason for filling out this form?

    1. Identified Close Contact
    2. Tested positive for COVID-19
31. COVID-19 Suspected Symptoms Present (Fever, cough, sore throat, loss of taste, headache, etc.)*

    1. Yes
    2. No
33. Have you been vaccinated for COVID 19 virus?

    1. Yes
    2. No
35. If yes, have you received a vaccine booster?

    1. Yes
    2. No
37. Has the employee been at work 2 days before the onset of symptoms?

    1. Yes
    2. No
    3. N/A
39. 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?
41. Date Expected COVID-19 Symptoms First Began
    Date Expected COVID-19 Symptoms First Began
43. Date of COVID-19 Test
    Date of COVID-19 Test
45. COVID-19 Test Results (If known)

    1. Positive
    2. Negative
47. Dates of Isolation
49. Estimated Date of first day of isolation?
    Estimated Date of first day of isolation?
51. Estimated date of last day of isolation?
    Estimated date of last day of isolation?
Leave This Blank:


53. 1. Receive an email copy of this form.
54. Email address

    This field is not part of the form submission.

55. Submit

* indicates a required field