COVID-19 Investigation

Welcome to your COVID-19 Investigation Form

Employer Address/Location:
Supervisor Phone:
When do you think you were first exposed to COVID-19?
Where do you think you may have contracted COVID-19?
If so, did other people, with whom you had direct contact at this location or jobsite, test positive?
If, so were they co-workers?
Do you suspect your exposure was work related?
Was the exposure work related?
Are you aware that in order to return to work after a confirmed positive COVID-19 test, you must provide confirmation of a negative COVID-19 test result to your manager?
Have you been to any social gatherings in the last 14 days?
Have you been out of the country in the past 60 days?
If so, please list the names of co-worker attendees who may have also had an exposure:
If "Yes" please list the employee names:
If so, were any of the other attendees at the social gathering co-workers?
Do you go on walks, hikes or have any exposure to the public?
How many times have the you gone to the grocery store or market in the last 30 days?
Have you visited places of worship, campgrounds, protests or beaches?
Do you practice social distancing, wear a mask and follow CDC guidelines?
Please list all activities you engaged in during the 14 days prior to being confirmed positive with COVID-19. If you are a field employee, please list all jobsites you have worked on in the 14 days prior to testing positive for COVID-19. Please include as much detail as possible including locations or people you may have been in contact with.
If so, please list the country or countries you visited:
If so, please list the type of social gathering and location.
If so, please list employee names:
If so, what jobsite or work location do you suspect you were exposed to COVID-19?
If so, please list the of places of worship, campgrounds, protests, or beaches you have visited:
Do you know when you were first exposed to COVID-19?
If so, please list locations:
Please list the person or object you suspect exposed you to COVID-19:
Date of COVID-19 positive test:
Job Description:
Supervisor Name:
Employer Contact Phone: