UCI Human Resources

Report New Coronavirus Cases

This form may be submitted by the individual with suspected or confirmed COVID-19 or by their supervisor or departmental HR on behalf of them.
- It is not necessary to report full-time telecommuters if they have not been on UCI property.
- Fields with asterisks (*) are mandatory.
Supervisor Guidance
- Please ensure that the individual stays at home and seeks medical advice. They may not come back to work without medical clearance.
- Please ask the individual to answer all calls from any 949 numbers. They may be contacted by COEH or Contact Tracing.
- During the pandemic you may ask the individual if they are experiencing symptoms of the pandemic virus.
- Contact your departmental/unit HR or a responsible university official to inform them of current circumstances, including any contact with COEH. Do not share the individual’s name with anyone other than departmental HR, central HR, SHC or COEH. The individual’s illness is individually identifiable health information.
- Please review additional instructions that will be provided to you when this form is submitted.

First Name*

Last Name*

Title

Email Address*

Phone Number - Mobile

Phone Number - Office

Department

UCInetID (if known)

Represented Worker*
YesNo

This case is:*
Experiencing covid symptoms.Pending test result.Lab-confirmed positive test result.Home Test (Antigen) confirmed positive test result.Physical or close contact with a confirmed COVID-19 Positive Individual (≥ 15 minutes cumulatively over a 24-hour period & within 6 feet).

Work Locations(s) - document specific UCI address(es) where the employee worked in the 14 days preceding the positive test*

Last Day On-Site*

Date of Onset of Symptoms

Test Date

Result Date

Please list all UCI individuals with whom the individual may have had direct (physical) or close (less than 6 feet for more than 15 minutes) contact with while at work. Include:

Names
Phone Numbers
Relationship to UCI (student, employee, contractor, etc.)

Please include other information which may be relevant

Please complete the following information regarding the person completing this form.

Same as above