COVID-19 Mandatory Weekly Testing Log

COVID-19 Mandatory Weekly Testing Log
Instructions:

All employees who are not fully vaccinated as defined by the Centers for Disease Control and do not have an approved testing exemption are required to participate in mandatory weekly Covid-19 testing. All testing should be conducted no more than 24 hours prior to the start of the employee's first shift of the administrative work week (Saturday 12:01 a.m. until the following Saturday 12:00 a.m.). Please accurately complete all sections on the form and upload your test results. Failure to complete mandatory weekly Covid-19 testing may result in disciplinary action.
Name *

Last Name First Name
Employee Identification Number (EID) *
Your EID is 2-5 digits and provided to you by Human Resources. Please ask your payroll clerk for this information if unknown.
Employee Department Number *
Phone Number *
Please enter a valid phone number to reach you in the event there are questions about your submission.
Covid-19 Test Results
Please select one of the following options below to report your Covid-19 test result: *

My Covid-19 test result is negative. I will upload proof of my negative test and report to work at my regular start time. My Covid-19 test result is positive. I will upload proof of my positive test result, notify my supervisor that I have tested positive so they can initiate the Covid-19 screening process and NOT report to work. I was unable to complete the Covid-19 test. I will notify my supervisor when I arrive to work at my regular start time.
Test Result Upload *

Cancel of
I certify that the foregoing information is true and correct. I understand that a knowing and willful false statement on this form, failure to complete this form, or failure to comply with safety requirements related to COVID-19 including testing or vaccination program directives may lead to disciplinary action up to and including dismissal.
Signature *

Clear
Should be Empty:

COVID-19 Mandatory Weekly Testing Log

Instructions:

Covid-19 Test Results