COVID Incident Report - Traveler Traveler's First and Last Name* Facility Name, City, State* 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 the traveler report this to the facility? If yes, provide information for questions below (A-D).*A. If yes to question 4, date and time reported to the facility? B. If yes to question 4, what is the contact information of the person the possible exposure was reported to? C. If yes to question 4, what communication method was used to report to the facility contact? Text, in-person, email? Please forward communication to your recruiter. D. If reported in-person, please provide a summary of the conversation.5. Please provide as much information (i.e. the amount of time spent with COVID positive individual, location of exposure, etc.) as possible of the direct link to the COVID exposure in the workplace.*6. What Personal Protective Equipment (PPE) was used by the traveler exposed?*7. Was there adequate resources of PPE available for the traveler to use?* 8. Is the traveler experiencing symptoms? If yes, provide info in the questions below (A and B)*A. When did the symptoms start?*B. What symptoms are/were experienced by the traveler?*9. Was the traveler tested at the facility? If no, where was the traveler tested? Was the traveler tested for any other illnesses (strep, flu, etc.)?*A. Did the traveler test positive for COVID? Yes No If "no" to question 9, what is the name and address of the facility the traveler tested? **Should be indicated on the test results. 10. What instructions has the facility provided the traveler regarding next steps?*11. What are the facility requirements to return to work (x number of days, proof of negative test, etc.)12. Does the traveler have an anticipated return to work date? If yes, what is it?*13. Was the traveler sent home from work?*14. How many hours did the traveler work that week, if any? *Anders Group 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 applicable15. When was the traveler's last day worked?* Name of person completing this form* Recruiter Name* Δ