COVID Exposure Report

Complete with as much detail as possible.

Name of person making this report: Name of person making this report: * First Last
Best number to reach you at: Best number to reach you at: * - ### - ### ####
Reporter Email- this email provided will be used to communicate with you and may be shared with the County Health Department. *
County of residence of effected person: *
Best phone number for effected person: (Only if not listed above) Best phone number for effected person: (Only if not listed above) - ### - ### ####
Center/Facility Name (Include classroom if applicable:
i.e. VS-VS1.
MO- Fiscal office *
What type of report is this?
i.e. exposure to COVID; PENDING test results; Positive test for self; Positive test result for staff member; Positive test result for student *
What type of test was given?
i.e. at home; PCR test *
Have you notified your direct supervisor of the results *

Have you notified your direct supervisor of the results Yes No
Name of Direct Supervisor Name of Direct Supervisor * First Last
Name of Ed Manager (if applicable) Name of Ed Manager (if applicable) First Last
Is the person for which this report is being filled out experiencing any symptoms? *

Is the person for which this report is being filled out experiencing any symptoms? Yes No
If experiencing symptoms, when did symptoms begin? (if known) If experiencing symptoms, when did symptoms begin? (if known) / MM / DD YYYY
If experiencing symptoms, what symptoms is the person experiencing?
List name and phone number for any staff/volunteer/contractor who may have been in close contact with the person indicated in this report. Also include: any non-staff present. i.e. IMESD, Dental, Mental Health, etc.

If none please state N/A