COVID-19 Health Services Online Reporting Form

Page 1 of 1

CISD Covid-19 Employee Reporting Form

1.	Employee’s Full Name/Nombre completo del empleado?*

2.	What is your phone number/¿Cuál es tu número de teléfono?*

3.	What is your email address/Cuál es tu dirección de correo electrónico?*

4.	What is the nature of this report/Cuál es la naturaleza de este informe?*

5.	If you selected “other” please explain here/ Si seleccionó "otro", explique aquí

6.	What campus are you assigned to/A qué campus te asignan?*

7.	If you are positive, when was your last day on campus? / Si es positivo, ¿cuándo fue su último día en el campus?
	mm/dd/yyyy

8.	Have you been vaccinated?

9.	If exposed, what is the date of exposure?
	mm/dd/yyyy

10.	If employee is positive, what is the date of first symptom?
	mm/dd/yyyy

11.	What is the date of the test?
	mm/dd/yyyy

12.	Was test a rapid test or PCR?

13.	Where was the test taken?

Done

Save

Cancel