COVID-19-Incident-Report-final-DAS-HR-Consulting-3.31.2020 (1)
| COVID-19 DOCUMENTATION | |
| PLEASE EMAIL COMPLETED REPORT IMMEDIATELY UPON BECOMING AWARE OF A SITUATION TO THE HUMAN RESOURCES DEPARTMENT | |
| DAS HR CONSULTING, LLC | |
| For assistance with completing this form, we are here to help! | |
| Dr. Di Sanchez (817) 343-0066 diann@dashrconsulting.com | |
| GENERAL INFORMATION | |
| YOUR NAME? | |
| DATE EXPOSED? | |
| YOUR AGE? | |
| YOUR SEX? | |
| WHAT IS YOUR E-MAIL? | |
| WHAT COUNTY DO YOU LIVE IN? | |
| YOUR HOME ADDRESS? | |
| YOUR PHONE NUMBER? | |
| DETAILS ON YOUR EXPOSURE TO COVID-19 | |
| HAVE YOU BEEN TESTED FOR THE COVID-19 VIRUS? (yes or no) | |
| HAVE YOU BEEN DIAGNOSED WITH COVID-19? (yes or no) | |
| WHAT ARE THE RESULTS OF YOUR COVID-19 TEST? (positive, negative, not known) | |
| DO YOU KNOW HOW YOU GOT EXPOSED TO COVID-19? | |
| FOR HOW LONG ARE YOU QUARANTINED? WHAT ARE THE DATES? | |
| IF YOU HAVE NOT BEEN DIAGNOSED WITH COVID-19, DO YOU HAVE ANY SYMPTOMS OF THE VIRUS? (yes or no) | |
| WHAT SYMPTOMS ARE YOU EXPERIENCING? | |
| ARE YOU CARING FOR SOMEONE WHO HAS BEEN QUARANTINED? (yes or no) | |
| WHAT IS YOUR RELATIONSHIP WITH THE INDIVIDUAL FOR WHOM YOU ARE CARING? | |
| HAS THE INDIVIDUAL YOU HAVE BEEN CARING FOR BEEN TESTED FOR COVID-19? (yes or no) | |
| IF THE INDIVIDUAL YOU HAVE BEEN CARING FOR HAS BEEN TESTED FOR COVID-19, DO THEY HAVE THE TEST RESULTS? (yes or no) | |
| IF SO, WHAT ARE THOSE TEST RESULTS? (positive, negative or not known) | |
| DOES THE INDIVIDUAL FOR WHOM YOU ARE CARING KNOW HOW THEY WERE EXPOSED TO THE VIRUS? (yes or no) | |
| IF YES, HOW WAS THE INDIVIDUAL EXPOSED TO THE VIRUS? | |
| ARE YOU AT HOME BECAUSE YOUR CHILD’S SCHOOL HAS BEEN CLOSED OR ARE UNABLE TO SECURE DAYCARE? (yes or no) | |
| MEDICAL PROVIDER INFORMATION | |
| NAME | |
| ADDRESS | |
| PHONE NUMBER | |
| COPY OF DOCTORS NOTE/REPORT (email a copy) | |
| DATE CLEARED (email proof) | |
| OTHERS WHO MAY HAVE BEEN EXPOSED TO THE INFECTED INDIVIDUAL | |
| NAME | NAME |
| ADDRESS | ADDRESS |
| PHONE NUMBER | PHONE NUMBER |
| NAME | NAME |
| ADDRESS | ADDRESS |
| PHONE NUMBER | PHONE NUMBER |
| Completed By/Date | |
