COVID Report Form
Form Instructions:
Fill out this electronic form for each employee (1 employee per form) with a positive COVID test result.
If you have questions about the form, please contact Wendy Priest at x333 or wpriest@mcr.health
This report form is for the employee only, not to report family or other household members that have tested positive for COVID.
Name of Employee
*
Employee's Job Title
*
Employee’s Department
*
Employee’s Work Location
*
Employee’s Contact Phone Number
*
First Date Employee Called Out
First Date Employee Called Out
*
MM slash DD slash YYYY
Where was the employee tested for COVID-19?
*
Yes – tested at an MCR Facility
Yes – tested at another facility – email test results to: HR Benefits and Leave Administration
No
Your Name
*
Date
*
MM slash DD slash YYYY
*Reminder to enter PTO in Kronos for time missed work. If the employee has exhausted PTO, time missed will be unpaid.
*Reminder – all employees must have a negative test result and must be cleared by Dr. Van Buren before they can return to work