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City of Missoula
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Case Employee COVID-19 Reporting Form 2

  1. For the Contact Tracer and Missoula Human Resources Designates to identify, report, and track COVID-19 cases and close contacts within City of Missoula workplaces.
  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. Phone Number
  9. City or Personal email will work.
  10. COVID-19 Suspected Symptoms Present (Fever, cough, sore throat, loss of taste, headache, etc.)*
  11. Have you been vaccinated for COVID 19 virus?
  12. If yes, has it been 2 weeks since your last vaccination or one shot of Johnson and Johnson?
  13. Has the employee been at work 2 days before the onset of symptoms?
  14. Can use this calculator if necessary
    COVID-19 Calculator
  15. Close Contact Identification
  16. Have you been within 6 feet of other city employees for 15 accumulative minutes over 24 hours within 2 days of symptom onset?
  17. Leave This Blank:

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