COVID-19 Self-Reporting Form Employee InformationCity Department(Required)Airport TerminalAirport ParkingAirport Industrial ParkAirport - other buildingsAirport AirfieldBED: General Manager Executive SecBED: Customer Energy ServicesBED: Finance AccountingBED: Risk Mgmt Gov't AffairsBED: EngineeringBED: Operations - LinecrewBED: Operations - MeetingBED: Operations - TechsBED: Operations - TbshooterBED: Operations - DispatchBED: Operations - MiscBED: McNeil Station - Aux OperatorBED: McNeil Station - Shift SupervisorBED: McNeil Station - Station OperatorBED: McNeil Station - YardworkerBED: McNeil Station - MaintenanceBED: McNeil Station - ForesterBED: McNeil Station - MiscCity Hall: CEDOCity Hall: MayorCity Hall: Clerk/TreasurerCity Hall: Planning/ZoningCity Hall: AttorneyCity Hall: ITCity Hall: AssessorDPW: Admin EngineeringDPW: AdminDPW: RecyclingDPW: Right of WayDPW: TrafficDPW: WaterDPW: WastewaterDPW: Equipment MaintenanceDPW: Code EnforcementParking: 47 S Winooski AveParking: 60 College StreetParking: 45 Cherry Street (Lakeview)Parking: Westlake Garage (attached to Lakeview)Station #1: 136 South Winooski AveStation #2: 132 North AveStation #3: 20 Mansfield AveStation #4: 1397 North AveStation #5: 23 Ferguson AveAdministration: 1 North AveLibraryMarketplaceHuman ResourcesFirehouse BuildingParks & Rec: Bldg Maintenance, 645 Pine StreetParks & Rec: Parks Maintenance, 645 Pine StreetParks & Rec: Cemetery - LakeviewParks & Rec: Cemetery - ElmwoodParks & Rec: Cemetery - Green MountainParks & Rec: PlannersParks & Rec: North BeachParks & Rec: Oakledge ParkParks & Rec: Leddy ParkParks & Rec: Calahan ParkParks & Rec: Schifilliti ParkParks & Rec: Schmanska ParkParks & Rec: Community BoathouseParks & Rec: Aborist StaffParks AdminPolice Dept: CivilianPolice Dept: SwornREIBTelecomEmployee Name(Required) First Last Employee Date of Birth MM slash DD slash YYYY Employee Phone(Required)Employee Email Contact TracingDid you have close contact with someone that tested positive?(Required) Yes No Close contact is defined by being within 6 feet of another individual for more than 15 minutes and who has tested positive for COVID-19.If "YES," what is the date of your last exposure to them?(Required) MM slash DD slash YYYY COVID-19 ExposureWhen did symptoms start?(Required) MM slash DD slash YYYY When was the last day you were physically at work?(Required) MM slash DD slash YYYY Vaccinated?(Required) Yes No Date of Last Shot(Required) MM slash DD slash YYYY Have you received your BOOSTER shot?(Required) Yes No If "YES" above, what date? MM slash DD slash YYYY Test Results(Required)Awaiting resultsNegativePositiveList of Close Contacts: Add RemoveFor COVID-19, a close contact is anyone who was within 6 feet of an infected person for a total of 15 minutes or more within a 24-hour period. The infection period is two days before the onset of symptoms, or from the date of test, whichever comes first.If you have tested POSITIVE for COVID-19:Have you had 2 negative ANTIGEN tests performed at least 24 hours apart, beginning no earlier than day 4? Yes No Date of Test 1 (If applicable MM slash DD slash YYYY Date of Test 2 (If applicable MM slash DD slash YYYY Are you asymptomatic? Yes No If you had symptoms, have they subsided? Yes No Have you had NO fever for at least 24 hours WITHOUT the use of medicine that helps reduce fevers? Yes No Δ Once you submit this form, your Safety Manager or HR Manager will contact you top let you know what your next steps will be.
