Covid-19 Tracing Form
Personal Information
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Department
Please Select
Administration/operations
Research and development
Marketing and sales
Human resources
Customer service
Accounting and finance
Please specify last date and time you were in the office
Date
-
Month
-
Day
Year
Date
Time
Hour Minutes
AM
PM
AM/PM Option
Symptoms
Please select if you have any of following symptoms and their degrees
Never
Mild
Moderate
Severe
high temperature/shivering
continuous cough
change to your sense of smell or taste
shortness of breath
feeling tired and exhausted
aching body
headache
sore throat
blocked/runny nose
loss of appetite
diarrhoe
feeling sick
Please write COVID testes and results
Did you recently meet other employee(s)?
Yes
No
If yes, name the employee(s)
Additional notes
Submit
Should be Empty: