First Name

Last Name

Date of Birth

MM/DD/YYYY

Employee ID #

Shift

Email Address (Work)

Email Address (Personal)

Phone # (Work)

Phone # (Personal)

Please understand that if WMCHealth determines that, based on your self-report of suspected exposure, you have been exposed and need to be quarantined, we will report this information to the department of health in your county of residence for follow up action.

By submitting this form, I hereby consent and authorize the Occupational Health Center (OHC) at Westchester Medical Center (WMC) and the healthcare providers at the OHC to disclose to my employer the results of a test for COVID19 and/or a test for COVID19 antibodies for the purposes of determining fitness for duty, fitness to return to duty and/or work assignment.

Fever or Chills	New Cough
Shortness of Breath	Sore Throat
Body Aches	Vomiting or Diarrhea
New Loss of Taste or Smell	Runny Nose
Headache

Fever	Dry cough
Sore throat	Shortness of breath
Diarrhea	Body aches
Headache	Loss of smell
Poor appetite	Malaise

LEAVE MANAGEMENT COVID-19