LEAVE/Exposure ASSESSMENT

EMPLOYEE INFORMATION

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* 1. First Intake Call

Date and Time

Date

Time

AM/PM

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* 2. Employee Information

Employee First Name *

Employee Last Name *

ID# *

Email Address

Phone Number *

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* 3. Company

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* 4. Business Unit

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* 5. SKIP - NO LONGER GATHERED

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* 6. Job Title: What position do you hold?

Office Position

Field Position

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* 7. HR Representative

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* 8. Last Day Worked

Insert Date

Date

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* 9. REASON for a Non-COVID Absence of 3 Days or More

COVID 19 Illness Related Absence (if Childcare/School Closing check option 5 below)

Medical Self Illness/Injury (non-COVID related)-PROCESS FMLA CLAIM IN LF

Medical qualifying FMLA caring for family member w illness/injury (non-COVID related)-PROCESS FMLA CLAIM IN LF

Medical non-qualifying FMLA caring for individual w illness/injury (non-COVID related)

Childcare/School Closing due to COVID

Personal non-illness/vacation

Question Title

* 10. Exposure Assessment Type: What is the reason for your call?

Illness

Direct Exposure - Coworker

Direct Exposure - Personal / Other

Direct Exposure - Living With or Caring For

Positive Subcontractor

Positive Symptomatic

Positive Symptomatic & Hospitalized

Positive Asymptomatic

Travel

Unable to Confirm Positive-EE Failed to Return

Pending - Presumed Positive (awaiting documentation)

Pending - Direct Exposure Assessment

Pending - Ill Exposure Assessment

LEAVE/Exposure ASSESSMENT

EMPLOYEE INFORMATION

Question Title

* 1. First Intake Call

Question Title

* 2. Employee Information

Question Title

* 3. Company

Question Title

* 4. Business Unit

Question Title

* 5. SKIP - NO LONGER GATHERED

Question Title

* 6. Job Title: What position do you hold?

Question Title

* 7. HR Representative

Question Title

* 8. Last Day Worked

Question Title

* 9. REASON for a Non-COVID Absence of 3 Days or More

Question Title

* 10. Exposure Assessment Type: What is the reason for your call?

Question Title

* 11. In your work setting are masks worn 100% of the time by everyone? If no, explain when mask mandates are/are not required.