COVID-19 Workplace Outbreak Reporting Form
AB 685 requires that employers notify employees of possible exposure to COVID-19 and report workplace outbreaks to the local health department.

This webform is to be completed by non-healthcare employers when three or more cases of COVID-19 are identified at a workplace within a 14-day period. This information should be submitted within 48 hours.

For guidance regarding two or less cases of COVID-19 please refer to our: Guidance for responding to COVID-19 in the workplace. Link: https://www.solanocounty.com/civicax/filebank/blobdload.aspx?BlobID=32708
Report Date
MM
/
DD
/
YYYY
Full Name *
Phone Number *
This is needed in case we need to get in touch with you.
Email
Position/ Title
Business Name or Employer *
Business/ Workplace Address *
Type of Business *
This is the industry of the business such as elementary school, clothing manufacturing, restaurant, or grocery store.
Total Number of Workers at Worksite
Please include all workers, including temporary and contract workers.
Number of Workers with COVID-19 *
This includes all workers known to have tested positive by either antigen test or PCR test in a 14 day period.
COVID-19 Positive Workers *
Please add one worker per line and answer the following: name, occupation, phone numbers, Solano resident (yes or no), when did symptoms start, last day at work?
Current situation
Describe current situation & preventative measures taken.
Do you require any of the following:
Submit
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