Covid-19 Tracing Form
Personal Information
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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
2 digit month, 2 digit day, 4 digit year
Date
Time
Hour Minutes
AM
PM
AM/PM Option
Symptoms
Please select if you have any of following symptoms and their degrees
Rows
Never
Mild
Moderate
Severe
high temperature/shivering
1
2
3
4
continuous cough
5
6
7
8
change to your sense of smell or taste
9
10
11
12
shortness of breath
13
14
15
16
feeling tired and exhausted
17
18
19
20
aching body
21
22
23
24
headache
25
26
27
28
sore throat
29
30
31
32
blocked/runny nose
33
34
35
36
loss of appetite
37
38
39
40
diarrhoe
41
42
43
44
feeling sick
45
46
47
48
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: