COVID-19 NOTIFICATION | Stan Clark Companies

When you are not able to work due to a positive test or COVID symptoms after exposure, please complete this form to assist us with contract tracing.

Name*
First Last
Location*
Have you recently been exposed to someone that tested positive?*
- Yes
- No
What is the relationship to the person where you were exposed?*

Please be specific - Roommate, friend, parent, sibling, boyfriend, girlfriend, etc.
What date was your COVID test was administered?*
MM slash DD slash YYYY
Please upload a copy of your test results. If you are using an at-home test, please sign and date your result before uploading the picture*
Max. file size: 400 MB.
Do you have any symptoms?*
- Yes
- No
What date did your symptoms first appear?
MM slash DD slash YYYY
Contact Tracing*
The CDC says that you are contagious 48 hours before symptoms appear. During this time frame, who do you think you were within 6 feet of for at least 15 minutes while at work? Please names individually - Not just "co-workers"
May we release that you have tested positive to other employees in order to assist with contact tracing?*
- Yes
- No
Signature*
Today's date*
MM slash DD slash YYYY