COVID 19 Survey HR Form

Please answer the following diagnostic questions so we can prioritize and attempt to guide you.

You can expect a response from HR within 4 hours during business hours.

    Your Full Name*

    Personal Email*

    Personal Phone Number*



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    I was directly exposed to COVID. Someone I was in direct contact with tested positive.*

    Date of Exposure:


    I was possibly exposed to COVID. I was in close contact with someone who is probable for COVID.*

    Date of Exposure:



    Describe possible COVID related symptoms:


    Test Date:


    Office Location*:

    Close contacts if you believe you exposed someone at your office or a clients:

    General Comments: