COVID Incident Report - Candidate Side Traveler's First and Last Name* Facility Name* 1. Date and Time of Report to Anders Group:* 2. Person that POSSIBLE exposure was reported to at Anders Group:* Usually recruiter name3. 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-D).*A. If yes to question 4, date and time reported to the facility? B. If yes to question 4, who was the possible exposure reported to - what is their name? C. If yes to question 4, what communication method was used to report to the facility contact? text, in-person, email? Ask them to forward the communication to you. D. If reported in-person, please provide a summary of the conversation.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.)*If "yes" to question 9, Were you tested at the facility? If "no" to question 9, where were you tested? Follow up question 9, did the facility have you tested for any other illnesses? IE 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? *will need time card for possible Guarantee of COVID hours.*Document Upload Drop files here or Select files Max. file size: 50 MB. Upload any related documents, if applicable13. When was your last day worked?* 14. Name of person completing this form* Candidate Recruiter Name* Client Recruiter Name* Δ