COVID Employee Health Reporting Form
Person Completing Form
Last Name First Name Middle Name
Employee Email Phone Type Employee Telephone #
DOB Assignment
Department / Campus
Physical Address
Street No. Street Name Direction
Apt No. City State
ZIP

Have you been exposed?   Yes     No

1.Date of Onset of Symptoms for EMPLOYEE
2.List Symptoms Experienced by EMPLOYEE
3.Date of EMPLOYEE'S COVID-19 Test (if applicable) 4.EMPLOYEE'S Testing Location (if applicable)
5.Does EMPLOYEE have copy of test results Yes     No 6.Date of test results received
7.Last Day Employee was at Work
8.While interacting with district staff/students, was the employee able to maintain social distancing and wear a mask at all times? Yes     No
9.If NO, please list names of district staff who employee interacted with for more than 15 minutes cumulative
10.In the event your test results are positive, is there another employee that needs to be notified? Quarantined? Yes     No 11.District locations employee may have entered in the last 72 hours
12.Did EMPLOYEE have close contact, within 6 feet for at least 15 cumulative minutes, with person symptomatic or confirmed COVID? Yes     No 13.Date of last close contact with person symptomatic or confirmed COVID
14.Was exposure ON On Campus
Off Campus		 15.Date of Onset of Symptoms for person you came in close contact with
16.Name of the person you came in close contact with (Index Case Name). This information is required for the Local Health Agency
17.Are you residing with any current SFDRCISD employees? Yes     No
18.Please list all members in your household
Last Name(s) First Name(s) Relationship Category Will be tested Method Department / Campus
19.Have you had contact with any other school district employee outside of working hours NOT LISTED ABOVE? If yes, please provide detail of interaction Yes     No
20.Have you previously used EPSL - Emergency Paid Leave? Yes     No
21.Exam Status? COVID Positive | COVID Negative | COVID Testing | Test Pending If Exposure is Positive |
22.Additional Notes

Vaccinated persons with an exposure to someone with suspected or confirmed COVID-19 are not required to quarantine if they meet all of the following criteria :

23.Are you fully vaccinated (i.e., ≥2 weeks following receipt of the second dose in a 2-dose series, or ≥2 weeks following receipt of one dose of a single-dose vaccine [not available yet])? Yes     No
24.Are you within 3 months following receipt of the last dose in the series? Yes     No
25.Have you remained asymptomatic since the current COVID-19 exposure? Yes     No

Please send Human Resources the following documents

  • The testing results,
  • Val Verde County Quarantine Notification
  • Medical documents (if not related to COVID), and
  • The Letter of Quarantine Completion as soon as you receive it (if applicable)
Document Type Upload Document
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