DOS CCT Investigation

Is this reports for a symptomatic employee or a close contact?*

Symptomatic Employee
Close Contact

CCT Investigator*

CCT Investigator Email address*

Name of Symptomatic Employee*

Name of Close Contact*

Is the Close Contact symptomatic*

No
Yes

Division*

Other Agency Name*

Supervisory Contact for other Agency

Supervisory Contact Phone

Supervisory Contact Email

Symptoms*

Cough
Fever
Shortness of Breath
Other

Other Symptoms*

Date of onset of symptoms?*

Time of onset of symptoms*

: HH

MM

Relevant Medical History*

Please enter any relevant medical history, none or not applicable

What location does the employee work?*

What does does the employee do for work?*

Close contact is defined as being within 6 feet of an individual for at least 10 minutes, although shorter timeframes can be considered depending on the individual circumstances, such as frequency of interaction, being directly coughed or sneezed on etc. Briefly walking by a person in the hallway, or other examples of brief contact, do not qualify as “close contact”.

Summary of investigation*

Please list below all the individuals identified as close contacts.*

Click the plus symbol to add more than one person. If there are no close contact, please enter "None identified".

Category 1
Employees who are sick with fever, cough, shortness of breath; or employees who have a Confirmed Positive COVID-19 Test.

Employees that fall under Category 1 shall remain out of work until:
 At least 7 days have passed since symptoms first appeared,
 At least 72 hours (3 days) have passed since recovery – which is defined as resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms.

Category 2
Asymptomatic individuals (people without symptoms) with direct contact (within 6 feet) with a Category 1 person
Employees may return to work after 14 days from last day of exposure to the individual, if no symptoms have developed. If the employee becomes symptomatic, they MUST immediately notify their supervisor and must submit the information via the DOS Employee sick notification form.

Category 3
Asymptomatic employee (people without symptoms) with high risk of exposure from travel by plane, train, or bus OR if they have attended any large group/business gatherings in other states? (In the past 14 days)

The employee may return to work after 14 days from last day of exposure, if no symptoms have developed. If the employee becomes symptomatic, they MUST immediately notify their supervisor and must submit the information via the DOS Employee sick notification form.

Category 4
Asymptomatic employee (people without symptoms) with low-risk contacts shall be allowed back to work.

If the employee becomes symptomatic, they MUST immediately initiate the callout procedure.

Close Contact Name	Division	Phone number	Category

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