COVID Incident Response Form - Candidate

Traveler's First and Last Name*
1. Date and Time of Report to Anders Group:*
2. Person that POSSIBLE exposure was reported to at Anders Group:*
Usually recruiter name
3. What method of communication was used? (text, in person, email, etc.)*
4. Did candidate report this to the facility? If yes, provide info for questions below (A-C).*
A. Date & time? B. To whom - what is their name? C. What communication method did they use? text, in-person, email? Ask them to forward this communication.
5. Description of POSSIBLE exposure and how long they were possibly exposed:*
6. What Protective Protection equipment (PPE) was used?*
7. Was there adequate resources of PPE available for you to use?*
8. Are they experiencing symptoms? If yes, what?*
9. Did the facility have you tested for COVID-19? Were you tested at the facility? If no, where were you tested? If yes or no, were you tested for any other illnesses? (strep, flu, etc.)*
10. What instructions has the facility provided to you about next steps and how/if you could return to work?*
11. Were you sent home from work?*
12. How many hours did you work that week, if any? When was your last day worked? *will need time card for possible Guarantee of COVID hours.*
13. Name of person completing this form*