Mandatory Reporting Form for Staff

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This form is for staff ONLY who have symptoms and are awaiting COVID test results, who have been exposed to a positive case of COVID, for those who have tested positive for COVID, or those who are caring for a dependent that has been exposed or tested positive.

Please fill out all required sections. If you have any questions, please contact Tanya Tate in HR at ttate@mctns.net

Full Name *

MCTNS E-Mail Address *

Date of Birth *

YYYY

Employee Telephone Number *

Employee's Job Title *

Employee School/Department *

Employee's Supervisor *

Have you tested positive for COVID? *

Yes- You must send a copy of your positive test results to Tanya Tate in HR

I am awaiting test results- I understand I must send results to Tanya Tate in HR

What date did you get tested?

YYYY

Are you out because you have been exposed to a positive case of COVID? *

Yes

I tested positive

Who were you exposed to? (only for those out due to exposure)

What date were you exposed?

YYYY

Are you out because you are caring for a dependent that has been quarantined or tested positive? *

Yes

What date was your dependent exposed or tested positive?

YYYY

What is your dependent's name and where are they quarantined from?

Are you out because you are caring for your child whose place of care is closed? *

Yes

If yes to the above question, please list the name of the child and the name of the school or child care provider that has closed:

What was your first date out of work or first day working remotely? *

YYYY

If you are certified staff, will you be teaching remotely during your quarantine? *

Yes

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