Request Workplace Covid-19 Positive Case Reporting

Submitter Name *

First

Last

Phone *

Email *

Business Name *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Project Name *

Project Address *

Address Line 1

Address Line 2

City

State

Zip Code

Type of Contractor *

Name of General Contractor if you are the subcontractor

General Contractor/Project Contact Phone Number *

Covid Positive Worker Name *

First

Last

Phone Number *

Date of Birth *

Worker Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Did employee have symptoms at the time of notification? *

Date of Symptom onset *

Date of positive test *

Worker’s role at workplace *

Date last worked *

CLOSE CONTACTS

Note: A COVID-19 positive worker that worked closer than 6’ for more than 15 minutes within a 24 hour time period

Complete information for EACH close contact

Close Contact #1

Close Contact Name

First

Last

Date of Birth

Phone Nmber

Home Address

Address Line 1

Address Line 2

City

State

Zip Code

Date of last exposure to case

Close Contact #2

Close Contact Name

First

Last

Date of Birth

Phone Number

Home Address

Address Line 1

Address Line 2

City

State

Zip Code

Date of last exposure to case

Date

Time

Close Contact #3

Close Contact Name

First

Last

Date of Birth

Phone Number

Home Address

Address Line 1

Address Line 2

City

State

Zip Code

Date of last exposure to case

Date

Time

Close Contact #4

Close Contact Name

First

Last

Date of Birth

Phone Number

Home Address

Address Line 1

Address Line 2

City

State

Zip Code

Date of last exposure to case

Close Contact #5

Close Contact Name

First

Last

Date of Birth

Phone Number

Home Address

Address Line 1

Address Line 2

City

State

Zip Code

Date of last exposure to case

If the COVID-19 Positive Worker has worked at multiple worksites within the last 14 days before symptoms started (if the worker had symptoms) or within the last 14 days before the date of collection of the positive test (if the worker had no symptoms). Please provide worksite names and addresses:

Suspected or Confirmed Cases of COVID-19 in the Workplace.

Reporting COVID-19 Cases to Cal/OSHA.

We do not make any warranty, expressed or implied, that your county COVID-19 case submittal complies with all laws, regulations, or standards.