COVID Incident Response Form – Facility

Name of person completing this form*

typically recruiter/account manager
Date form completed*
Name and title of client/facility contact that is confirming facility-side information*
Complete all fields below
Date & Time of report to Facility by Anders Group employee*
Name of facility contact reported to and their title:*
What method of communication was used? i.e. text, in person, email, etc.*
Details of possible COVID-19 exposure:*
Is the candidate being tested for COVID or anything else?*
Was there adequate resources of PPE available for the traveler to use?*
What are the next steps for how and when the candidate will be cleared to return to work?*
Upload Documents
Max. file size: 50 MB.
Upload any related documents, if applicable
Candidate Recruiter Name*
Client Recruiter Name*

Complete all fields below