Positive Worksite Case

Please fill out the information below.

The Utah Department of Health (UDOH) under its authority in Utah Code §26-6-3, of the Utah Communicable Disease Control Act requests information on possible contacts for a worksite-related exposure to COVID-19. Under Utah Code §26-6-6(8), individuals aware of those with a communicable disease are required to report the positive person and other possible suspected exposures. Please provide employee names and contact information (full name, DOB, gender, phone, email, address) for further investigation and follow-up.

The information you provide is saved in a confidential and secure database. Only the state or local health department contact tracing teams will have access to this information. This information will help public health learn more about COVID-19 spread and possibly contact individuals who were exposed to determine if quarantine is necessary.

HIPAA exempts the release of personally-identifiable for the purpose of public health and OSHA use. Employers have access to their employer’s date of birth and can contact their HR department if the supervisor doesn’t have it on hand. Health Information Privacy.

For critical infrastructure (essential workers) safety information please visit and download this pdf.

Matched to EPITrax CMR

If no: Please verify person's information

Yes

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EpiTrax matched CMR

Name of Business

* must provide value

Address of Business

Unit number or Store number

City

State

Zip code

Point of Contact Name

* must provide value

Point of Contact Phone Number

Email address

CMR

First Name of Positive Case

* must provide value

Middle name of positive case

Last name of positive case

* must provide value

Gender

Male

Female

Unkown

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Job Position

Date of Birth

* must provide value

M-D-Y

Primary phone number for positive case

Email address

Date Last worked

* must provide value

M-D-Y

Was this employee placed in quarantine?

Yes

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Start of Quarantine date

M-D-Y

Was this employee considered to be a critical infrastructure or "essential worker"?

For critical infrastructure (essential workers) safety information please visit and download this pdf.

Yes

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Symptom Onset Date (If symptomatic)

M-D-Y

Street Address

Unit number

City

Zip Code

Additional Notes

Please include other days worked while symptomatic or not listed above.

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