[Inland Regional Center] Vendor Report: COVID-Positive Staff

IRC VENDOR REPORT

FOR STAFF TESTING POSITIVE FOR COVID-19

Vendor/Facility Name

IRC Vendor #

Vendor Type

Vendor/Facility Liaison

How many staff newly tested positive for COVID-19?

Were consumers exposed to any staff who tested positive?

Yes

If yes, how many consumers were or may have been exposed?

INSTRUCTIONS: FOR ANY STAFF WHO RECENTLY TESTED POSITIVE, PLEASE ENTER THE DATE THEY TESTED POSITIVE, THE DATE THEY WERE TAKEN OFF SCHEDULE, AND THE APPROXIMATE DATE OF THEIR RETURN.

PLEASE NOTE: IF MORE THAN 5 STAFF TESTED POSITIVE, PLEASE DESCRIBE THE ADDITIONAL NUMBER OF STAFF IN THE COMMENTS SECTION ALONG WITH THE DATES EACH ADDITIONAL STAFF TESTED POSITIVE, THE DATES EACH ADDITIONAL STAFF WAS TAKEN OFF SCHEDULE AND THE APPROXIMATE DATES OF EACH ADDITIONAL STAFF'S RETURN TO WORK

Staff #1

Date staff #1 tested positive *

Date taken off schedule *

Approximate date of return to work *

Staff #2

Date staff #2 tested positive

Date taken off schedule

Approximate date of return to work

Staff #3

Date staff #3 tested positive

Date taken off schedule

Approximate date of return to work

Staff #4

Date staff #4 tested positive

Date taken off schedule

Approximate date of return to work

Staff #5

Date staff #5 tested positive

Date taken off schedule

Approximate date of return to work

Comments:

Vendor email address

THANK YOU AND BE WELL!