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Step One

This form is to collect information for three or more employees that have a positive COVID-19 test result within 14 calendar days.
For additional information or guidance, call (530) 283-6400.
Industry Type:*
Facility Name: *
Please indicate name of Workplace
Facility Street Address:*
City (Facility Address)*
Facility Zip Code*
Point of Contact:
(Name of the person that will be the point of contact for the facility COVID-19 cases)
Point of Contact Phone Number:
Indicate the phone number of the facility point of contact.
Point of contact Email Address:
Indicate the e-mail address of the point of contact.
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CONFIRMED COVID-19 CASE INFORMATION - CASE #1

Indicate the appropriate category for the person reported.*
1. Employee
1. Other
First Name of the COVID-19 positive case.*
Last Name of the COVID-19 positive case.
Street Address (Home Address):*
Indicate the home address of the COVID-19 positive case.
City (Home Address):*
Zip Code (Home Address):
Last Day of Work:*
Last Day of Work:
Indicate the last day the COVID-19 positive case visited the facility.
Date of Birth (DOB):*
Date of Birth (DOB):
Indicate the DOB of the COVID-19 positive case.
Gender:*
1. Female
1. Male
1. Non-Binary
1. Other
Phone Number:
Job Title:
NAICS Code:
Work Area/Location Within Facility:
Work Schedule/Shift:
Symptoms
Did the positive COVID-19 case have any symptoms at the time of reporting?
1. Yes
1. No
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CONFIRMED COVID-19 CASE INFORMATION - CASE #2

Indicate the appropriate category for the person reported.
1. Employee
2. Other
First Name of the COVID-19 positive case.
Last Name of the COVID-19 positive case.
Street Address (Home Address):
Indicate the home address of the COVID-19 positive case.
City (Home Address):
Zip Code (Home Address):
Last Day of Work:*
Last Day of Work:
Indicate the last day the COVID-19 positive case visited the facility.
Date of Birth (DOB):
Date of Birth (DOB):
Indicate the DOB of the COVID-19 positive case.
Gender:
1. Female
1. Male
1. Non-Binary
1. Other
Phone Number:
Job Title:
NAICS Code:
Work Area/Location Within Facility:
Work Schedule/Shift:
Symptoms:
Did the positive COVID-19 case have any symptoms at the time of reporting?
1. Yes
1. No
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CONFIRMED COVID-19 CASE INFORMATION - CASE #3

Indicate the appropriate category for the person reported.
1. Employee
2. Other
First Name of the COVID-19 positive case.
Last Name of the COVID-19 positive case.
Street Address (Home Address):
Indicate the home address of the COVID-19 positive case.
City (Home Address):
Zip Code (Home Address):
Last Day of Work:
Last Day of Work:
Indicate the last day the COVID-19 positive case visited the facility.
Date of Birth (DOB):
Date of Birth (DOB):
Indicate the DOB of the COVID-19 positive case.
Gender:
1. Female
1. Male
1. Non-Binary
1. Other
Phone Number:
Job Title:
NAICS Code:
Work Area/Location Within Facility:
Work Schedule/Shift:
Symptoms:
Did the positive COVID-19 case have any symptoms at the time of reporting?
1. Yes
1. No
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CLOSE CONTACT(S) AT WORKPLACE

A “close contact” is considered someone who stayed within 6 feet of a COVID-19 infected person for more than 15 minutes after that person was diagnosed, or up to two days before that person first developed symptoms. This applies even if both people are wearing a face covering, mask, or an N95 respirator. Close contact can also take place during brief interactions where there is unprotected direct contact with the COVID-19 infected person’s body secretions (e.g., sneezing, coughing, sharing utensils, exchanging saliva). Cumulative exposures that add up to 15 minutes within a day may be considered close contact depending on intensity of exposure (e.g., if the person had multiple interactions in a confined space with a symptomatic COVID-19 infected person).
Close Contacts*
Do you have any close contacts to report?
1. No
2. Yes
Full Name of Close Contact #1
Phone Number of Close Contact #1
Email of Close Contact #1
Date of Last Exposure of Close Contact #1
Date of Last Exposure of Close Contact #1
Date of Last Exposure of Close Contact #1
Full Name of Close Contact #2
Phone Number of Close Contact #2
Email of Close Contact #2
Date of Last Exposure of Close Contact #2
Date of Last Exposure of Close Contact #2
Date of Last Exposure of Close Contact #2
Full Name of Close Contact #3
Phone Number of Close Contact #3
Email of Close Contact #3
Date of Last Exposure of Close Contact #3
Date of Last Exposure of Close Contact #3
Date of Last Exposure of Close Contact #3
Full Name of Close Contact #4
Phone Number of Close Contact #4
Email of Close Contact #4
Date of Last Exposure of Close Contact #4
Date of Last Exposure of Close Contact #4
Date of Last Exposure of Close Contact #4
Full Name of Close Contact #5
Phone Number of Close Contact #5
Email of Close Contact #5
Date of Last Exposure of Close Contact #5
Date of Last Exposure of Close Contact #5
Date of Last Exposure of Close Contact #5
Full Name of Close Contact #6
Phone Number of Close Contact #6
Email of Close Contact #6
Date of Last Exposure of Close Contact #6
Date of Last Exposure of Close Contact #6
Date of Last Exposure of Close Contact #6
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ADDITIONAL INFORMATION

Is there any additional information you would like to report?

Leave This Blank:

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

This field is not part of the form submission.
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COVID-19 Workplace Case and Contact Reporting

Steps

Step One

CONFIRMED COVID-19 CASE INFORMATION - CASE #1

CONFIRMED COVID-19 CASE INFORMATION - CASE #2

CONFIRMED COVID-19 CASE INFORMATION - CASE #3

CLOSE CONTACT(S) AT WORKPLACE

ADDITIONAL INFORMATION