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]

  1. 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
  2. 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]