COVID-19 Outbreak Reporting Form

Details of Person involved in Illness

Employee Name: Contact No:
Male:

Home Address: Female:

Date of
Birth:
Work Details
Location: Department:
Employment or Relationship status to Organisation
Employee
COVID-19 affected Party: Contractor Position:
Visitor/Client
Does the employee work for any
Yes No
other organisation?

Affected Party (Area Visited):

Description of Event:
Date of COVID-19 Affected: Time of Occurrence:

Description of Occurrence:

When did the Occur?

During Work time During break from Work
Journey/to/From Work (Insurer Journey form) Other

Where did the Occur:

After the Affected

Return to Work Go to the Hospital
Did the person: Go Home Other
Go to the Doctor

Document Ref: NC-IMS-F-49 Rev.00 Page 1 of 2

COVID-19 Outbreak Reporting Form
Corrective Action:

Preventive Action:

Document Ref: NC-IMS-F-49 Rev.00 Page 2 of 2