Appendix C: Investigating COVID-19 Cases
All personal identifying information of COVID-19 cases or persons with COVID-19 symptoms, and any employee required medical records will be kept confidential unless disclosure is required or permitted by law. Un-redacted information on COVID-19 cases will be provided to the local health department, CDPH, Cal/OSHA, the National Institute for Occupational Safety and Health (NIOSH) immediately upon request, and when required by law.
Date: [enter date COVID-19 case – suspected/confirmed - became known to the employer]
Name of person conducting the investigation: [enter name]
Name of COVID-19 case (employee or non-employee*) and contact information: [enter information]
Occupation (if non-employee*, why they were in the workplace): [enter information]
*If we are made aware of a non-employee COVID-19 case in our workplace
Names of employees/representatives involved in the investigation: [enter information]
Date investigation was initiated: [enter information]
Locations where the COVID-19 case was present in the workplace during the high-risk exposure period, and activities being performed: [enter information]
Date and time the COVID-19 case was last present and excluded from the workplace: [enter information]
Date of the positive or negative test and/or diagnosis: [enter information]
Date the case first had one or more COVID-19 symptoms, if any: [enter information]
Information received regarding COVID-19 test results and onset of symptoms (attach documentation): [enter information]
Summary determination of who may have had a close contact with the COVID-19 case during the high- risk exposure period. Attach additional information, including:
- The names of those found to be in close contact.
- Their vaccination status.
- When testing was offered, including the results and the names of those that were exempt from testing because:
- They returned to work per our return-to-work criteria and have remained symptom free for 90 days (or a different period than 90 days if it is required by a CDPH regulation or order) or, for those that never developed symptoms, for 90 days (or a different period than 90 days if it is required by a CDPH regulation or order) after the initial positive test.
- The names of those close contacts that were excluded per our Exclusion of COVID-19 Cases and Employees who had Close Contact requirements.
- The names of those close contacts exempt from exclusion requirements because:
- They were fully vaccinated before the close contact and did not develop COVID-19 symptoms, and are required to wear a face covering and maintain six feet of distance from others at the workplace for 10 days following the last date of close contact.
- They returned to work per our return-to-work criteria and have remained symptom free, and are required to wear a face covering and maintain six feet of physical distance from others at the workplace for 10 days following the last date of close contact.
- They never developed symptoms and are required to wear a face covering and maintain six feet of physical distance from others at the workplace for 10 days following the last date of close contact.
[enter information]
- Notice given (within one business day, in a way that does not reveal any personal identifying information of the COVID-19 All employees who were on the premises at the same worksite as the COVID-19 case during the high-risk exposure period
- Their authorized representatives (If applicable, the notice required by Labor Code section 6409.6(a) (2) and (c))
Names of employees that were notified: | Names of their authorized representatives: |
Date |
---|---|---|
Independent contractors and other employers on the premises at the same worksite as the COVID-19 case during the high-risk exposure period.
Names of individuals that were notified | Date |
---|---|
What were the workplace conditions that could have contributed to the risk of COVID-19 exposure?
[enter information]
What could be done to reduce exposure to COVID-19?
[enter information]
Was local health department notified? Date?
[enter information]