COVID-19 Contact Tracing Form

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II.	DHS COVID-19 Positive Individual’s Work Activity 
Please list all work activities, floors visited, meetings attended (including lunches, etc.) that you participated in starting 48 hours before the illness onset.  (Symptomatic individuals)
FROM: MM / DD / YYYY   THROUGH: The last date worked at a DHS worksite: MM / DD / YYYY
OR
Please list all work activities, floors visited, meetings attended (including lunches, etc.) that you participated in starting 2 days prior to a positive specimen collection or until the time you were isolated. (Asymptomatic individuals)
FROM: MM / DD / YYYY   THROUGH: The last date worked at a DHS worksite: MM / DD / YYYY
  
  This may not be all 14 days.

If the COVID-19 positive individual indicates visiting meeting rooms, ask them to identify where they sat in the meeting room. Use that information to inform whether others in meeting room were in 6 ft range for at least 15 minutes. 
(See the description of close contact1 in the work place, in the footnote below).

Notes



Date of symptom onset:
MM / DD / YYYY




         Locations/Notes

Locations/Notes

1 day before symptom onset       MM / DD / YYYY


 2 day before symptom onset
 MM / DD / YYYY


1 day after symptom onset  MM / DD / YYYY



2 days after symptom onset
MM / DD / YYYY


3 days after symptom onset MM / DD / YYYY


4 days after symptom onset
MM / DD / YYYY


5 days after symptom onset  MM / DD / YYYY


6 days after symptom onset  MM / DD / YYYY


7 days after symptom onset  MM / DD / YYYY


8 days after symptom onset  MM / DD / YYYY


9 days after symptom onset  MM / DD / YYYY


10 days after symptom onset  MM / DD / YYYY






























III.	Exposed Individual(s)
Please complete the table below for all close contact exposures to a DHS COVID-19 positive individual which occurred
    1) 48 hours from the date of illness onset through the last date worked at a DHS worksite (symptomatic individuals)OR 
    2) 2 days prior to a positive specimen collection  or until the date the COVID-19 positive individual was isolated (asymptomatic individuals)



Name
(First and Last) 

Location of Exposed       Individuals
(e.g., department, floor, desk location)

       Phone Number 
      (mobile or home)
                and     
         Work Email 
       
Date of last exposure to the DHS COVID-19 Positive Individual
MM/DD/YYYY
     










































      Add additional rows as needed