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City of Missoula
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Covid-19 Reporting

  1. Employee COVID-19 Reporting Form 1

    For a City of Missoula Employee who has tested for COVID-19 to complete. Purpose: For the City of Missoula Human Resources to identify, report, and track COVID-19 cases and close contacts within City of Missoula workplaces and employees.

  2. * Required

  3. Enter Phone as 10 numbers only

  4. City or Personal email

  5. First & Last Name

  6. Enter Phone as 10 numbers only

  7. First & Last Name

  8. First & Last Name

  9. City or Personal email will work.

  10. If contacted by MCCHD, what was the reason?

  11. COVID-19 Suspected Symptoms Present (Fever, cough, sore throat, loss of taste, headache, etc.)*

  12. Have you been vaccinated for COVID 19 virus?*

  13. If yes, has it been 2 weeks since your last vaccination and not more than 3 months?

  14. Has the employee been at work 2 days before the onset of symptoms?

  15. COVID-19 Test Results (If known)

  16. Dates of Isolation

  17. Leave This Blank:

  18. This field is not part of the form submission.