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EMPLOYEE & COVID RELATED ILLNESS FORM
Contact Us
First Name
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Last Name
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Department
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Cell Phone
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Describe Symptom(s) of Illness
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Date Symptoms First Started
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MM slash DD slash YYYY
I tested positive for COVID on the following date:
MM slash DD slash YYYY
Physician Documentation
Max. file size: 768 MB.
COVID Test Results
Max. file size: 768 MB.
Acknowledgement
(Required)
I understand that in order to be paid for absent days related to COVID, I may use EIB (first) or PTO to get paid.
Per established CDC guidelines, I will need to be away from AVALA for 5 days since my positive COVID test. Upon return to work I will need to mask through day 10.
To return to work, the following criteria must be met:
At least 1 day (24 hs) have passed since recovery defined as resolution of fever without the use of fever-reducing medications; improvement in symptoms (e.g. cough, shortness of breath, diarrhea, etc.); & at least 5 days have passed since symptoms first appeared. Additionally, upon return to work, it is an expectation that a surgical face mask will be worn for universal source control in the work setting (see below). Fully vaccinated people who have an exposure (direct contact or are within 6 ft for 15 mins or more over a 24 hr period) to someone who has a COVID-19 infection & remain asymptomatic do not need to quarantine if they meet the criteria: Are 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) at the time of exposure, AND Have remained asymptomatic since the current COVID-19 exposure. [Note: If the person develops symptoms of COVID-19 within the 14 days after exposure, they should self-isolate immediately for 5 days after symptom onset, and get tested], AND Are not an inpatient in a healthcare setting or resident of a congregate setting (nursing home, correctional facility, etc.). All close contacts should still watch for symptoms of COVID-19 for 14 days following an exposure and follow all prevention guidance. Prevention guidance includes wearing a mask, staying at least 6 feet away from others, avoiding crowds, avoiding poorly ventilated spaces, covering coughs and sneezes, washing hands often, following CDC travel guidance, and following any applicable workplace or school guidance, including guidance related to personal protective equipment use for COVID-19 testing.
Notes/Additional Comments
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