Covid Exposure Report Example Officer Exposed:* First Last PIN#:* Officer Phone #:*Officer Email:* DR/CN:* Date of Exposure:* MM slash DD slash YYYY Time Reported:**Use Military Time : Hours Minutes Supervisor Notified:* PPE Worn:* N95 Mask Mask Other Gloves Gown Safety Goggles None Source Symptoms:* Fever Sore Throat Cough Difficulty Breathing None Was there physical contact with the subject?* Yes No Was there less than 6 ft contact with the subject?* Yes No Was the address previously flagged to alert of universal precautions?* Yes No Was the subject medically diagnosed with COVID-19?* Yes No Did EMS respond (Fire or Med)?* Yes No Was report of injury completed?* Yes No Source Name: First Last Source Date of Birth: Email Address* Enter your email address to receive a copy of this formEmailThis field is for validation purposes and should be left unchanged.
