HR Covid Notices Form

HR COVID NOTICES FORM

This form documents employee notice to Human Resources regarding a COVID-19 related matter, including illness, exposure, testing, accommodation needs, and requests for leave or return-to-work clearance. Complete all applicable sections fully and sign the acknowledgement at the end of this document.

Personal Information

Position Information

Start Date:

COVID-19 Notice (Employee Report)

Check all that apply and provide the requested dates and details. The Company will assess workplace safety needs, provide guidance, and take steps required by applicable public health laws.

I have tested positive for SARS-CoV-2 (COVID-19). Test date: . Test type:

I am experiencing COVID-19 related symptoms. Symptom onset date: . Describe symptoms:

I have been exposed to a person known to be COVID-19 positive. Date of exposure: . Location / context of exposure:

Vaccination and Testing Consent

Vaccination status (check all that apply):

Fully vaccinated Booster received Not vaccinated

I consent to COVID-19 testing and to the Company recording and sharing my test results internally for public health and workplace safety purposes, consistent with applicable law:

Consent to testing Consent to sharing results with designated Company personnel and public health authorities as required

Isolation, Leave, and Return-to-Work

I request leave or workplace accommodation as a result of this COVID-19 matter:

Request paid leave Request unpaid leave Request temporary remote work

If cleared by a healthcare provider for return to work, provide clearance date and provider name: Cleared date: Provider:

Accommodation Request

Preferred effective date for accommodation:

Privacy, Data Handling, and Legal Notices

The Company will treat health information provided in this form as confidential medical information. Information will be disclosed only to supervisors, occupational health personnel, human resources, and public health authorities as required by law or necessary to protect the health and safety of employees. All disclosures will be limited to the minimum necessary information.

The Company prohibits retaliation against any employee for reporting illness, exposure, or requesting accommodation under applicable law. Retaliatory conduct should be reported immediately to Human Resources.

Authorization and Certification

By signing below I certify under penalty of perjury that the information provided on this form is true and complete to the best of my knowledge. I authorize the Company to obtain or verify information related to this notice for purposes of evaluating leave, benefits, accommodations, and workplace safety. This authorization includes contacting my healthcare provider(s) and, where necessary, prior employers to verify dates of employment and leave for safety-related determinations.

I understand that the Company will use received medical documentation solely for legitimate, job-related purposes and to comply with applicable laws. I agree to provide any documentation reasonably requested by the Company to substantiate the need for leave or accommodation.

Employment History (For verification purposes)

Dates Employed:

Dates Employed:

Education

References (Professional)

Legal Disclosures

At-Will Employment: Unless otherwise set forth in a written agreement signed by an authorized Company representative, employment is at-will and may be terminated by either the employee or the Company at any time with or without cause and with or without notice.

Equal Employment Opportunity: The Company provides equal employment opportunities to all employees and applicants without regard to race, color, religion, sex (including pregnancy, childbirth, or related medical conditions), national origin, age, disability, genetic information, or other protected status in accordance with applicable law.

Employee Certification

I certify that all information provided on this HR COVID Notices Form is true and complete to the best of my knowledge. I understand that intentionally providing false information may subject me to disciplinary action up to and including termination.

I authorize the Company to contact relevant healthcare providers, previous employers, or public health authorities as necessary to verify information for leave, accommodation, or safety determinations. I understand that medical documentation provided will be used only for legitimate, job-related purposes.

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