---
title: "COVID-19 Employee Assessment!  Incident Report!"
description: "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 DA..."
url: https://www.dashrconsulting.com/covid-19-employee-assessment-incident-report/
date: 2020-03-31
modified: 2020-04-01
author: "Dr. Di Ann Sanchez"
image: https://www.dashrconsulting.com/wp-content/uploads/CoronaVirusHeader-Final-3.jpg
categories: ["DAS HR Consulting Company News", "HR Compliance", "HR Legislative Updates", "HR Trends", "Human Resources"]
tags: ["covid", "COVID-19", "COVID-19 compliance", "Employers compliance with COVID-19", "Families First Act COVID 19"]
type: post
lang: en
---

# COVID-19 Employee Assessment!  Incident Report!

[COVID-19-Incident-Report-final-DAS-HR-Consulting-3.31.2020 (1)](https://www.dashrconsulting.com/wp-content/uploads/COVID-19-Incident-Report-final-DAS-HR-Consulting-3.31.2020-1.pdf)

| **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** |
| **EMAIL** | **EMAIL** |
|   |   |
| **NAME** | **NAME** |
| **ADDRESS** | **ADDRESS** |
| **PHONE NUMBER** | **PHONE NUMBER** |
| **EMAIL** | **EMAIL** |
|   |   |
|   |   |
|   |   |
|   |   |
|   |   |
| **Completed By/Date ** |   |

![](https://www.dashrconsulting.com/wp-content/uploads/DAS-Vert-Color-Small-300x53.jpg)![](https://www.dashrconsulting.com/wp-content/uploads/CoronaVirusHeader-Final-3-300x126.jpg)