COVID REPORT FORM

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?*
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