app.perfectforms.com
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urlscan Pro
129.146.53.210
Public Scan
URL:
https://app.perfectforms.com/PresentationServer/App.aspx/Play/vsWGggcm?f=vsWGggcm
Submission: On February 26 via manual from US — Scanned from DE
Submission: On February 26 via manual from US — Scanned from DE
Form analysis 1 forms found in the DOM
<form id="PF_49" class="form formBoxShadow" style="height: 950px; width: 684px; display: block; left: 458px; top: 100px;">
<div id="PF_52Container" class="PageContainer" style="z-index:0;left:0px;top:0px;">
<div id="PF_52" name="PF_52" class="page" style="width: 684px; height: 950px; background-color: rgb(255, 255, 255); display: block;">
<span><input id="PF_1" name="PF_1" type="text" maxlength="99" value="" autocomplete="on" class="textinput" onclick="return false;" data-validation-engine="validate[required]"
style="font-family: verdana; font-size: 10px; font-style: normal; border-width: 1px; border-style: solid; z-index: 100; background-color: rgb(255, 255, 255); color: rgb(51, 51, 51); border-color: rgb(173, 170, 170); left: 42px; top: 304px; height: 16px; line-height: 16px; width: 50px; font-weight: normal !important; display: block;"><label
id="PF_1label" class="offscreen" for="PF_1">ee id input</label></span><span><input id="PF_53" name="PF_53" type="text" maxlength="10" value="" onkeypress="return isNumberKey(event)" class="textinput" onclick="return false;"
ob="validate[required]"
style="font-family: verdana; font-size: 10px; font-style: normal; border-width: 1px; border-style: solid; z-index: 53; background-color: rgb(255, 255, 255); color: rgb(51, 51, 51); border-color: rgb(173, 170, 170); left: 76px; top: 330px; height: 16px; line-height: 16px; width: 104px; font-weight: normal !important; display: block;"
alt=""><label id="PF_53label" class="offscreen" for="PF_53">phone number input</label></span><span><select id="PF_54" name="PF_54" class="dropdown" aria-label="dept fun drop down"
style="z-index: 661; font-family: verdana; font-size: 10px; font-style: normal; background-color: rgb(255, 255, 255); color: rgb(51, 51, 51); border-color: rgb(173, 170, 170); left: 501px; top: 379px; height: 20px; width: 157px; font-weight: normal !important; display: block;">
<option value="1" selected="selected">Select One</option>
<option value="9">Admin</option>
<option value="8">Commercial</option>
<option value="2">Finance</option>
<option value="4">HR</option>
<option value="3">IT</option>
<option value="5">Legal</option>
<option value="6">Logistics</option>
<option value="7">Operations</option>
</select><label id="PF_54label" class="offscreen" for="PF_54">Selection</label></span><span><select id="PF_46" name="PF_46" class="dropdown" aria-label="BU drop down"
style="z-index: 10; font-family: verdana; font-size: 10px; font-style: normal; background-color: rgb(255, 255, 255); color: rgb(51, 51, 51); border-color: rgb(173, 170, 170); left: 273px; top: 378px; height: 20px; font-weight: normal !important; display: block;">
<option value="1" selected="selected">Select One</option>
<option value="27">Beverage & Dairy Foods HQ</option>
<option value="28">Beverage & Dairy Foods Plants</option>
<option value="26">Central Area Council</option>
<option value="25">Consumer Retail</option>
<option value="24">Corporate HQ</option>
<option value="23">Dairy Brands HQ</option>
<option value="19">Dairy One</option>
<option value="20">DFA Financing</option>
<option value="21">DFA Insurance</option>
<option value="22">Empire Livestock</option>
<option value="17">Farm Services Operations</option>
<option value="18">Farm Services & Sustainability</option>
<option value="16">Farm Supplies</option>
<option value="15">Fluid North</option>
<option value="14">Fluid South</option>
<option value="13">Ice Cream</option>
<option value="12">Ingredients HQ</option>
<option value="11">Ingredients Plants</option>
<option value="10">Mideast Area Council</option>
<option value="9">Milk Marketing HQ</option>
<option value="8">Mountain Area Council</option>
<option value="7">Northeast Area Council</option>
<option value="6">Risk Management</option>
<option value="5">SEMO</option>
<option value="4">Southeast Area Council</option>
<option value="3">Southwest Area Council</option>
<option value="2">Western Area Council</option>
</select><label id="PF_46label" class="offscreen" for="PF_46">Selection</label></span><span><select id="PF_45" name="PF_45" class="dropdown" aria-label="div drop down"
style="z-index: 658; font-family: verdana; font-size: 10px; font-style: normal; background-color: rgb(255, 255, 255); color: rgb(51, 51, 51); border-color: rgb(173, 170, 170); left: 71px; top: 379px; height: 20px; width: 157px; font-weight: normal !important; display: block;">
<option value="1" selected="selected">Select One</option>
<option value="7">Beverage & Dairy Foods</option>
<option value="2">Corporate</option>
<option value="3">Dairy Brands</option>
<option value="5">Farm Services</option>
<option value="4">Ingredient Solutions</option>
<option value="6">Milk Marketing</option>
</select><label id="PF_45label" class="offscreen" for="PF_45">Selection</label></span><span><input id="PF_55" name="PF_55" type="text" maxlength="99" value="" class="textinput" onclick="return false;"
data-validation-engine="validate[required]"
style="font-family: verdana; font-size: 10px; font-style: normal; border-width: 1px; border-style: solid; z-index: 114; background-color: rgb(255, 255, 255); color: rgb(51, 51, 51); border-color: rgb(173, 170, 170); left: 232px; top: 424px; height: 16px; line-height: 16px; width: 230px; font-weight: normal !important; display: block;"
readonly=""><label id="PF_55label" class="offscreen" for="PF_55">loc covid contact input name</label></span><span><select id="PF_56" name="PF_56" class="dropdown" data-validation-engine="validate[required]"
aria-label="reason for report drop down"
style="z-index: 597; font-family: verdana; font-size: 10px; font-style: normal; background-color: rgb(255, 255, 255); color: rgb(51, 51, 51); border-color: rgb(173, 170, 170); left: 241px; top: 495px; height: 20px; width: 270px; font-weight: normal !important; display: block;">
<option value=""></option>
<option value="1">I am sick (potential COVID-19 symptoms)</option>
<option value="2">I was exposed to a COVID-19 positive person</option>
</select><label id="PF_56label" class="offscreen" for="PF_56">Selection</label></span>
<div id="PF_57" rel="False" class="typetext text text" style="z-index: 190; font-family: verdana; font-size: 10px; font-style: normal; left: 504px; top: 669px; height: 14px; width: 91px; font-weight: bold !important; display: block;"> Released:
</div>
<div id="PF_58" rel="False" class="typetext text text" style="z-index: 609; font-family: verdana; font-size: 10px; font-style: normal; left: 308px; top: 669px; height: 14px; width: 95px; font-weight: bold !important; display: block;"> Date
Admitted: </div>
<div id="PF_59" rel="False" class="typetext text text" style="z-index: 100; font-family: verdana; font-size: 10px; font-style: normal; left: 20px; top: 303px; height: 14px; width: 26px; font-weight: bold !important; display: block;"> ID: </div>
<span><input id="PF_18" name="PF_18" type="text" maxlength="99" value="" autocomplete="on" class="textinput" onclick="return false;"
style="font-family: verdana; font-size: 10px; font-style: normal; border-width: 1px; border-style: solid; z-index: 657; background-color: rgb(255, 255, 255); color: rgb(51, 51, 51); border-color: rgb(173, 170, 170); left: 246px; top: 353px; height: 16px; line-height: 16px; width: 183px; font-weight: normal !important; display: block;"
readonly=""><label id="PF_18label" class="offscreen" for="PF_18">rep location input</label></span><span><input id="PF_13" name="PF_13" type="text" maxlength="99" value="" class="textinput" onclick="return false;"
style="font-family: verdana; font-size: 10px; font-style: normal; border-width: 1px; border-style: solid; z-index: 54; background-color: rgb(255, 255, 255); color: rgb(51, 51, 51); border-color: rgb(173, 170, 170); left: 246px; top: 329px; height: 16px; line-height: 16px; width: 183px; font-weight: normal !important; display: block;"
readonly=""><label id="PF_13label" class="offscreen" for="PF_13">location input</label></span>
<fieldset id="PF_20Container" class="PageContainer" style="z-index:7;left:199px;top:624px;">
<div id="PF_20" name="PF_20" class="group radiogroup hidden" ob="validate[funcCall[groupRequired]]"
style="width: 104px; height: 38px; background-color: rgb(255, 255, 255); border-width: 1px; border-style: none; text-indent: 0px; border-color: rgb(0, 0, 0); border-radius: 0px !important; display: none;">
<div id="PF_21div" class="radiobuttonContainer " style="font-family:'verdana';font-size:10px;font-weight:normal !important;font-style:normal;z-index:172;height:18px;width:45px;left:2px;top:20px;white-space:nowrap;text-overflow:ellipsis;">
<input type="radio" name="PF_20" ob="validate[required,groupRequired{}]" id="PF_21" value="1" class="radiobutton indivualRadio" tabindex="" aria-label="Yes" title="Yes"><label id="PF_21label" for="PF_21" style="width:23px;">Yes</label>
</div>
<div id="PF_28div" class="radiobuttonContainer " style="font-family:'verdana';font-size:10px;font-weight:normal !important;font-style:normal;z-index:173;height:18px;width:55px;left:47px;top:20px;white-space:nowrap;text-overflow:ellipsis;">
<input type="radio" name="PF_20" ob="validate[required,groupRequired{}]" id="PF_28" value="2" class="radiobutton indivualRadio" tabindex="" aria-label="No" title="No"><label id="PF_28label" for="PF_28" style="width:33px;">No</label>
</div>
</div>
</fieldset>
<fieldset id="PF_24Container" class="PageContainer" style="z-index:103;left:446px;top:601px;">
<div id="PF_24" name="PF_24" class="group radiogroup" data-validation-engine="validate[funcCall[groupRequired]]"
style="width:95px;height:38px;background-color:#ffffff;border-width:1px;border-style: none;border-radius: 0px !important; behavior: url('https://app.perfectforms.com/pie.htc');text-indent:0px;border-color:#000000;">
<div id="PF_25div" class="radiobuttonContainer"
style="font-family: verdana; font-size: 10px; font-style: normal; z-index: 133; height: 17px; width: 41px; left: 2px; top: 20px; white-space: nowrap; text-overflow: ellipsis; font-weight: normal !important; display: inline;">
<input type="radio" name="PF_24" data-validation-engine="validate[required,groupRequired[PF_24]]" id="PF_25" value="1" class="radiobutton indivualRadio" tabindex="" aria-label="Yes" title="Yes" style="display: inline;"><label
id="PF_25label" for="PF_25" style="width:19px;">Yes</label>
</div>
<div id="PF_60div" class="radiobuttonContainer"
style="font-family: verdana; font-size: 10px; font-style: normal; z-index: 134; height: 18px; width: 49px; left: 42px; top: 20px; white-space: nowrap; text-overflow: ellipsis; font-weight: normal !important; display: inline;">
<input type="radio" name="PF_24" data-validation-engine="validate[required,groupRequired[PF_24]]" id="PF_60" value="2" class="radiobutton indivualRadio" tabindex="" aria-label="No" title="No" style="display: inline;"><label
id="PF_60label" for="PF_60" style="width:27px;">No</label>
</div>
</div>
</fieldset>
<fieldset id="PF_61Container" class="PageContainer" style="z-index:594;left:244px;top:525px;">
<div id="PF_61" name="PF_61" class="group radiogroup" data-validation-engine="validate[funcCall[groupRequired]]"
style="width:123px;height:38px;background-color:#ffffff;border-width:1px;border-style: none;border-radius: 0px !important; behavior: url('https://app.perfectforms.com/pie.htc');text-indent:0px;border-color:#000000;">
<div id="PF_62div" class="radiobuttonContainer"
style="font-family: verdana; font-size: 10px; font-style: normal; z-index: 640; height: 18px; width: 45px; left: 2px; top: 20px; white-space: nowrap; text-overflow: ellipsis; font-weight: normal !important; display: inline;">
<input type="radio" name="PF_61" data-validation-engine="validate[required,groupRequired[PF_61]]" id="PF_62" value="1" class="radiobutton indivualRadio" tabindex="" aria-label="Yes" title="Yes" style="display: inline;"><label
id="PF_62label" for="PF_62" style="width:23px;">Yes</label>
</div>
<div id="PF_63div" class="radiobuttonContainer"
style="font-family: verdana; font-size: 10px; font-style: normal; z-index: 641; height: 18px; width: 55px; left: 43px; top: 20px; white-space: nowrap; text-overflow: ellipsis; font-weight: normal !important; display: inline;">
<input type="radio" name="PF_61" data-validation-engine="validate[required,groupRequired[PF_61]]" id="PF_63" value="2" class="radiobutton indivualRadio" tabindex="" aria-label="No" title="No" style="display: inline;"><label
id="PF_63label" for="PF_63" style="width:33px;">No</label>
</div>
</div>
</fieldset><span><input id="PF_15" name="PF_15" type="text" maxlength="99" value="" class="textinput" onclick="return false;" tabindex="-1"
style="font-family: verdana; font-size: 10px; font-style: normal; border-width: 1px; border-style: solid; z-index: 45; background-color: rgb(255, 255, 255); color: rgb(51, 51, 51); border-color: rgb(173, 170, 170); left: 418px; top: 304px; height: 16px; line-height: 16px; width: 234px; font-weight: normal !important; display: block;"
readonly=""><label id="PF_15label" class="offscreen" for="PF_15">job title input</label></span><span><select id="PF_30" name="PF_30" class="dropdown" aria-label="test results Drop-Down"
style="z-index: 611; font-family: verdana; font-size: 10px; font-style: normal; background-color: rgb(255, 255, 255); color: rgb(51, 51, 51); border-color: rgb(173, 170, 170); left: 95px; top: 570px; height: 20px; width: 106px; font-weight: normal !important; display: block;">
<option value=""></option>
<option value="2">Positive</option>
<option value="3">Negative</option>
<option value="4">In progress</option>
<option value="5">No test/won't test</option>
</select><label id="PF_30label" class="offscreen" for="PF_30">Selection</label></span><span><input id="PF_14" name="PF_14" type="text" maxlength="99" value="" class="textinput" onclick="return false;" tabindex="-1"
style="font-family: verdana; font-size: 10px; font-style: normal; border-width: 1px; border-style: solid; z-index: 46; background-color: rgb(255, 255, 255); color: rgb(51, 51, 51); border-color: rgb(173, 170, 170); left: 144px; top: 304px; height: 16px; line-height: 16px; width: 203px; font-weight: normal !important; display: block;"
readonly=""><label id="PF_14label" class="offscreen" for="PF_14">EE name </label></span>
<div id="PF_32div" class="dateinputContainer" style="z-index: 615; left: 387px; top: 544px; display: inline;">
<input id="PF_32" name="PF_32" type="text" class="dateinput hasDatepicker" aria-label="test date input" data-validation-engine=" validate[funcCall[validFormatDate]] "
style="font-family: verdana; font-size: 10px; font-style: normal; border-width: 1px; border-style: solid; z-index: 615; background-color: rgb(255, 255, 255); color: rgb(51, 51, 51); border-color: rgb(173, 170, 170); width: 77px; font-weight: normal !important; display: inline;"
alt="" rel=""><img class="ui-datepicker-trigger" src="/PresentationServer/Content/images/calendar.gif" alt="..." title="..." style="opacity: 1;">
</div>
<div id="PF_64" rel="False" class="typetext text text" style="z-index: 46; font-family: verdana; font-size: 10px; font-style: normal; left: 103px; top: 303px; height: 19px; width: 45px; font-weight: bold !important; display: block;"> Name:
</div>
<div id="PF_65" rel="False" class="typetext text text" style="z-index: 52; font-family: verdana; font-size: 10px; font-style: normal; left: 19px; top: 329px; height: 14px; width: 63px; font-weight: bold !important; display: block;"> Phone #:
</div>
<div id="PF_66" rel="False" class="typetext text text" style="z-index: 619; font-family: verdana; font-size: 10px; font-style: normal; left: 213px; top: 571px; height: 14px; width: 90px; font-weight: bold !important; display: block;"> Date of
Results: </div>
<div id="PF_67" rel="False" class="typetext text text" style="z-index: 44; font-family: verdana; font-size: 10px; font-style: normal; left: 362px; top: 305px; height: 14px; width: 63px; font-weight: bold !important; display: block;"> Job Title:
</div>
<div id="PF_68div" class="dateinputContainer" style="z-index: 620; left: 309px; top: 570px; display: inline;">
<input id="PF_68" name="PF_68" type="text" class="dateinput hasDatepicker" aria-label="results date" data-validation-engine=" validate[funcCall[validFormatDate]] "
style="font-family: verdana; font-size: 10px; font-style: normal; border-width: 1px; border-style: solid; z-index: 620; background-color: rgb(255, 255, 255); color: rgb(51, 51, 51); border-color: rgb(173, 170, 170); width: 77px; font-weight: normal !important; display: inline;"
alt="" rel=""><img class="ui-datepicker-trigger" src="/PresentationServer/Content/images/calendar.gif" alt="..." title="..." style="opacity: 1;">
</div>
<div id="PF_69" rel="False" class="typetext text text" style="z-index: 621; font-family: verdana; font-size: 10px; font-style: normal; left: 19px; top: 595px; height: 15px; width: 422px; font-weight: bold !important; display: block;"> When were
you last present at a company facility/company function? </div>
<div id="PF_70" rel="False" class="typetext text text" style="z-index: 141; font-family: verdana; font-size: 10px; font-style: normal; left: 492px; top: 546px; height: 14px; width: 65px; font-weight: bold !important; display: block;"> Test
Type: </div>
<div id="PF_71" rel="False" class="typetext text text" style="z-index: 618; font-family: verdana; font-size: 10px; font-style: normal; left: 324px; top: 546px; height: 14px; width: 65px; font-weight: bold !important; display: block;"> Test
Date: </div>
<div id="PF_72" rel="False" class="typetext text text" style="z-index: 608; font-family: verdana; font-size: 10px; font-style: normal; left: 18px; top: 571px; height: 14px; width: 76px; font-weight: bold !important; display: block;"> Test
Results: </div>
<div id="PF_73" rel="False" class="typetext text text" style="z-index: 603; font-family: verdana; font-size: 10px; font-style: normal; left: 18px; top: 546px; height: 14px; width: 216px; font-weight: bold !important; display: block;"> Has a
COVID-19 test been completed? </div><button aria-label="Button" title="Button" rel="#eeeeee,eeeeee" id="PF_74" class="button hidden" onclick="return false;"
style="width: 65px; height: 22px; z-index: 12; font-family: verdana; font-size: 10px; font-style: normal; left: 450px; top: 908px; border-style: solid; border-width: 1px; border-radius: 0px; border-color: rgb(0, 0, 0); overflow: hidden; text-overflow: ellipsis; white-space: nowrap; position: absolute; font-weight: normal !important; color: rgb(0, 0, 0); background: -webkit-linear-gradient(top, rgb(238, 238, 238), rgb(238, 238, 238)); display: none;">Button
</button>
<div id="PF_76" rel="False" class="typetext text text" style="z-index: 602; font-family: verdana; font-size: 10px; font-style: normal; left: 19px; top: 670px; height: 14px; width: 170px; font-weight: bold !important; display: block;"> Have you
been hospitalized? </div>
<div id="PF_77" rel="False" class="typetext text text" style="z-index: 601; font-family: verdana; font-size: 10px; font-style: normal; left: 324px; top: 519px; height: 14px; width: 216px; font-weight: bold !important; display: block;"> Symptoms
first began? </div>
<div id="PF_78" rel="False" class="typetext text text" style="z-index: 600; font-family: verdana; font-size: 10px; font-style: normal; left: 18px; top: 497px; height: 14px; width: 217px; font-weight: bold !important; display: block;"> Reason
for report? (Please select one) </div>
<div id="PF_79" rel="False" class="typetext text text" style="z-index: 610; font-family: verdana; font-size: 10px; font-style: normal; left: 18px; top: 519px; height: 14px; width: 226px; font-weight: bold !important; display: block;"> Have you
experienced any symptoms? </div>
<div id="PF_80div" class="dateinputContainer" style="z-index: 622; left: 426px; top: 592px; display: inline;">
<input id="PF_80" name="PF_80" type="text" class="dateinput hasDatepicker" title="" aria-label="last at work date" data-validation-engine=" validate[funcCall[validFormatDate]] "
style="font-family: verdana; font-size: 10px; font-style: normal; border-width: 1px; border-style: solid; z-index: 622; background-color: rgb(255, 255, 255); color: rgb(51, 51, 51); border-color: rgb(173, 170, 170); width: 77px; font-weight: normal !important; display: inline;"
rel=""><img class="ui-datepicker-trigger" src="/PresentationServer/Content/images/calendar.gif" alt="..." title="..." style="opacity: 1;">
</div>
<div id="PF_81" rel="False" class="typetext text text" style="z-index: 654; font-family: verdana; font-size: 10px; font-style: normal; left: 439px; top: 354px; height: 14px; width: 69px; font-weight: bold !important; display: block;"> City,
State: </div>
<div id="PF_82" rel="False" class="typetext text text" style="z-index: 33; font-family: verdana; font-size: 10px; font-style: normal; left: 439px; top: 330px; height: 14px; width: 69px; font-weight: bold !important; display: block;"> City,
State: </div>
<div id="PF_83" rel="False" class="typetext text text" style="z-index: 656; font-family: verdana; font-size: 10px; font-style: normal; left: 131px; top: 354px; height: 14px; width: 111px; font-weight: bold !important; display: block;">
Reporting Location: </div>
<div id="PF_84" rel="False" class="typetext text text" style="z-index: 43; font-family: verdana; font-size: 10px; font-style: normal; left: 190px; top: 330px; height: 14px; width: 63px; font-weight: bold !important; display: block;"> Location:
</div>
<div id="PF_85" rel="False" class="typetext text text" style="z-index: 623; font-family: verdana; font-size: 10px; font-style: normal; left: 18px; top: 691px; height: 14px; width: 275px; font-weight: bold !important; display: block;"> Please
provide a brief summary of the situation. </div><span><input id="PF_86" name="PF_86" type="text" maxlength="99" value="" autocomplete="on" class="textinput" onclick="return false;"
style="font-family: "sans-serif"; font-size: 10px; font-style: normal; border-width: 2px; border-style: solid; z-index: 8; background-color: rgb(255, 255, 255); color: rgb(51, 51, 51); border-color: rgb(173, 170, 170); left: 13px; top: 238px; height: 211px; line-height: 211px; width: 647px; font-weight: normal !important; display: block;"><label
id="PF_86label" class="offscreen" for="PF_86">Text Input 17</label></span>
<fieldset id="PF_31Container" class="PageContainer" style="z-index:595;left:233px;top:498px;">
<div id="PF_31" name="PF_31" class="group radiogroup" data-validation-engine="validate[funcCall[groupRequired]]"
style="width:120px;height:44px;background-color:#ffffff;border-width:1px;border-style: none;border-radius: 0px !important; behavior: url('https://app.perfectforms.com/pie.htc');text-indent:0px;border-color:#000000;">
<div id="PF_87div" class="radiobuttonContainer"
style="font-family: verdana; font-size: 10px; font-style: normal; z-index: 637; height: 18px; width: 50px; left: 13px; top: 20px; white-space: nowrap; text-overflow: ellipsis; font-weight: normal !important; display: inline;">
<input type="radio" name="PF_31" data-validation-engine="validate[required,groupRequired[PF_31]]" id="PF_87" value="yes" class="radiobutton indivualRadio" tabindex="" aria-label="Yes" title="Yes" style="display: inline;"><label
id="PF_87label" for="PF_87" style="width:28px;">Yes</label>
</div>
<div id="PF_88div" class="radiobuttonContainer"
style="font-family: verdana; font-size: 10px; font-style: normal; z-index: 638; height: 18px; width: 54px; left: 54px; top: 20px; white-space: nowrap; text-overflow: ellipsis; font-weight: normal !important; display: inline;">
<input type="radio" name="PF_31" data-validation-engine="validate[required,groupRequired[PF_31]]" id="PF_88" value="no" class="radiobutton indivualRadio" tabindex="" aria-label="No" title="No" style="display: inline;"><label
id="PF_88label" for="PF_88" style="width:32px;">No</label>
</div>
</div>
</fieldset>
<div id="PF_89" rel="False" class="typetext text text" style="z-index: 41; font-family: verdana; font-size: 11px; font-style: normal; left: 56px; top: 262px; height: 35px; width: 439px; font-weight: normal !important; display: block;"> Enter
your employee ID below or use the button to search for it. <br>You may search by first name, last name, email or a portion of one of these. </div><span><input id="PF_90" name="PF_90" type="text" maxlength="99" value="" class="textinput"
onclick="return false;"
style="font-family: "sans-serif"; font-size: 10px; font-style: normal; border-width: 2px; border-style: solid; z-index: 1; background-color: rgb(255, 255, 255); color: rgb(51, 51, 51); border-color: rgb(173, 170, 170); left: 13px; top: 765px; height: 132px; line-height: 132px; width: 647px; font-weight: normal !important; display: block;"><label
id="PF_90label" class="offscreen" for="PF_90">Text Input 17</label></span><span><input id="PF_91" name="PF_91" type="text" maxlength="99" value="" class="textinput" onclick="return false;"
style="font-family: "sans-serif"; font-size: 10px; font-style: normal; border-width: 2px; border-style: solid; z-index: 1; background-color: rgb(255, 255, 255); color: rgb(51, 51, 51); border-color: rgb(173, 170, 170); left: 13px; top: 462px; height: 292px; line-height: 292px; width: 647px; font-weight: normal !important; display: block;"><label
id="PF_91label" class="offscreen" for="PF_91">Text Input 17</label></span><button aria-label="Search" title="Search" rel="#002F6C,002F6C" id="PF_92" class="button" onclick="return false;"
style="width: 65px; height: 20px; z-index: 42; font-family: verdana; font-size: 10px; font-style: normal; color: rgb(255, 252, 252); left: 499px; top: 267px; border-style: solid; border-width: 1px; border-radius: 0px; border-color: rgb(0, 47, 108); overflow: hidden; text-overflow: ellipsis; white-space: nowrap; position: absolute; font-weight: bold !important; background: -webkit-linear-gradient(top, rgb(0, 47, 108), rgb(0, 47, 108)); display: block;">Search
</button><span><input id="PF_16" name="PF_16" type="text" maxlength="99" value="" autocomplete="on" class="textinput" onclick="return false;"
style="font-family: verdana; font-size: 10px; font-style: normal; border-width: 1px; border-style: solid; z-index: 655; background-color: rgb(255, 255, 255); color: rgb(51, 51, 51); border-color: rgb(173, 170, 170); left: 508px; top: 353px; height: 16px; line-height: 16px; width: 144px; font-weight: normal !important; display: block;"
readonly=""><label id="PF_16label" class="offscreen" for="PF_16">rep loc city, state input</label></span><span><input id="PF_17" name="PF_17" type="text" maxlength="99" value="" class="textinput" onclick="return false;"
style="font-family: verdana; font-size: 10px; font-style: normal; border-width: 1px; border-style: solid; z-index: 34; background-color: rgb(255, 255, 255); color: rgb(51, 51, 51); border-color: rgb(173, 170, 170); left: 508px; top: 329px; height: 16px; line-height: 16px; width: 144px; font-weight: normal !important; display: block;"
readonly=""><label id="PF_17label" class="offscreen" for="PF_17">loc city state input</label></span>
<div id="PF_50div" class="dateinputContainer" style="z-index: 20; left: 454px; top: 209px; display: inline;">
<input id="PF_50" name="PF_50" type="text" class="dateinput hasDatepicker" title="" aria-label="Date of notice" data-validation-engine=" validate[funcCall[validFormatDate]] "
style="font-family: verdana; font-size: 10px; font-style: normal; border-width: 1px; border-style: solid; z-index: 20; background-color: rgb(255, 255, 255); color: rgb(51, 51, 51); border-color: rgb(173, 170, 170); width: 77px; font-weight: normal !important; display: inline;"
rel=""><img class="ui-datepicker-trigger" src="/PresentationServer/Content/images/calendar.gif" alt="..." title="..." style="opacity: 1;">
</div>
<div id="PF_93" rel="False" class="typetext text text" style="z-index: 19; font-family: verdana; font-size: 10px; font-style: normal; left: 363px; top: 211px; height: 14px; width: 84px; font-weight: bold !important; display: block;"> Date of
Notice: </div><span><input id="PF_51" name="PF_51" type="text" maxlength="99" value="" class="textinput" onclick="return false;"
style="font-family: verdana; font-size: 10px; font-style: normal; border-width: 1px; border-style: solid; z-index: 17; background-color: rgb(255, 255, 255); color: rgb(51, 51, 51); border-color: rgb(173, 170, 170); left: 588px; top: 211px; text-align: right; height: 16px; line-height: 16px; width: 69px; font-weight: normal !important; display: block;"><label
id="PF_51label" class="offscreen" for="PF_51">time of notification input</label></span>
<div id="PF_33div" class="dateinputContainer" style="z-index: 607; left: 457px; top: 517px; display: inline;">
<input id="PF_33" name="PF_33" type="text" class="dateinput hasDatepicker" aria-label="symptoms first date" data-validation-engine=" validate[funcCall[validFormatDate]] "
style="font-family: verdana; font-size: 10px; font-style: normal; border-width: 1px; border-style: solid; z-index: 607; background-color: rgb(255, 255, 255); color: rgb(51, 51, 51); border-color: rgb(173, 170, 170); width: 77px; font-weight: normal !important; display: inline;"
alt="" rel=""><img class="ui-datepicker-trigger" src="/PresentationServer/Content/images/calendar.gif" alt="..." title="..." style="opacity: 1;">
</div>
<div id="PF_94" rel="False" class="typetext text text" style="z-index: 18; font-family: verdana; font-size: 10px; font-style: normal; left: 554px; top: 211px; height: 14px; width: 41px; font-weight: bold !important; display: block;"> Time:
</div>
<div id="PF_95" rel="False" class="typetext text text" style="z-index: 222; font-family: verdana; font-size: 10px; font-style: normal; left: 445px; top: 381px; height: 14px; width: 62px; font-weight: bold !important; display: block;"> Function:
</div>
<div id="PF_96" rel="False" class="typetext text text" style="z-index: 13; font-family: verdana; font-size: 10px; font-style: normal; left: 245px; top: 380px; height: 14px; width: 36px; font-weight: bold !important; display: block;"> BU: </div>
<div id="PF_97" rel="False" class="typetext text text" style="z-index: 220; font-family: verdana; font-size: 10px; font-style: normal; left: 18px; top: 381px; height: 14px; width: 71px; font-weight: bold !important; display: block;"> Division:
</div>
<div id="PF_98" rel="False" class="typetext text text" style="z-index: 19; font-family: verdana; font-size: 10px; font-style: normal; left: 97px; top: 426px; height: 14px; width: 139px; font-weight: bold !important; display: block;"> Facility
COVID Contact: </div>
<div id="PF_99" rel="False" class="typetext text text" style="z-index: 606; font-family: verdana; font-size: 10px; font-style: normal; left: 557px; top: 520px; height: 14px; width: 41px; font-weight: bold !important; display: block;"> Time:
</div>
<div id="PF_100div" class="dateinputContainer" style="z-index: 189; left: 564px; top: 668px; display: inline;">
<input id="PF_100" name="PF_100" type="text" class="dateinput hasDatepicker" title="" aria-label="release date" data-validation-engine=" validate[funcCall[validFormatDate]] "
style="font-family: verdana; font-size: 10px; font-style: normal; border-width: 1px; border-style: solid; z-index: 189; background-color: rgb(255, 255, 255); color: rgb(51, 51, 51); border-color: rgb(173, 170, 170); width: 77px; font-weight: normal !important; display: inline;"
rel=""><img class="ui-datepicker-trigger" src="/PresentationServer/Content/images/calendar.gif" alt="..." title="..." style="opacity: 1;">
</div>
<div id="PF_101div" class="dateinputContainer" style="z-index: 605; left: 396px; top: 668px; display: inline;">
<input id="PF_101" name="PF_101" type="text" class="dateinput hasDatepicker" title="" aria-label="hospital date" data-validation-engine=" validate[funcCall[validFormatDate]] "
style="font-family: verdana; font-size: 10px; font-style: normal; border-width: 1px; border-style: solid; z-index: 605; background-color: rgb(255, 255, 255); color: rgb(51, 51, 51); border-color: rgb(173, 170, 170); width: 77px; font-weight: normal !important; display: inline;"
rel=""><img class="ui-datepicker-trigger" src="/PresentationServer/Content/images/calendar.gif" alt="..." title="..." style="opacity: 1;">
</div><span><textarea id="PF_102" name="PF_102" maxlength="210" autocomplete="on" class="textarea" ob="validate[required]"
style="font-family: verdana; font-size: 10px; font-style: normal; border-width: 1px; border-style: solid; z-index: 612; background-color: rgb(255, 255, 255); color: rgb(51, 51, 51); border-color: rgb(173, 170, 170); left: 19px; top: 708px; height: 40px; width: 635px; overflow-x: hidden; font-weight: normal !important; display: block;"></textarea></span>
<div id="PF_103" rel="False" class="typetext text text"
style="z-index: 613; color: rgb(0, 0, 0); font-family: verdana; font-size: 9px; font-style: italic; left: 293px; top: 692px; height: 14px; width: 99px; font-weight: normal !important; display: block;"> Max 200 characters </div>
<div id="PF_104" rel="False" class="typetext text text" style="z-index: 616; font-family: verdana; font-size: 11px; font-style: normal; left: 19px; top: 790px; height: 33px; width: 481px; font-weight: bold !important; display: block;"> Were you
WITHIN 6 FEET OF OTHER EMPLOYEES FOR MORE THAN 15 MINUTES OVER A 24 HOUR PERIOD within 48 hours of symptom onset. </div><img id="PF_105" title=""
src="/PresentationServer/ImageAspectRatioHandler.ashx?id=RS1xR2owZ0FnQUFnN0FRTiY2NzgmMTk1JmJvdGgmMjE5NTM1JjAuMQ==" class="picture" role="presentation" alt=""
style="z-index: 199; left: 5px; top: 5px; width: 678px; height: 195px; display: block;">
<fieldset id="PF_106Container" class="PageContainer" style="z-index:645;left:508px;top:797px;">
<div id="PF_106" name="PF_106" class="group" data-validation-engine="validate[funcCall[groupRequired]]"
style="width:150px;height:25px;background-color:#ffffff;border-width:1px;border-style: none;border-radius: 0px !important; behavior: url('https://app.perfectforms.com/pie.htc');text-indent:0px;border-color:#000000;">
<div id="PF_107div" class="radiobuttonContainer"
style="font-family: verdana; font-size: 10px; font-style: normal; z-index: 643; height: 18px; width: 56px; left: 5px; top: 0px; white-space: nowrap; text-overflow: ellipsis; font-weight: normal !important; display: inline;">
<input type="radio" name="PF_106" id="PF_107" value="1" class="radiobutton indivualRadio" tabindex="" aria-label="Yes" title="Yes" style="display: inline;"><label id="PF_107label" for="PF_107" style="width:34px;">Yes</label>
</div>
<div id="PF_110div" class="radiobuttonContainer"
style="font-family: verdana; font-size: 10px; font-style: normal; z-index: 644; height: 18px; width: 57px; left: 64px; top: 0px; white-space: nowrap; text-overflow: ellipsis; font-weight: normal !important; display: inline;">
<input type="radio" name="PF_106" id="PF_110" value="2" class="radiobutton indivualRadio" tabindex="" aria-label="No" title="No" style="display: inline;"><label id="PF_110label" for="PF_110" style="width:35px;">No</label>
</div>
</div>
</fieldset><button aria-label="Next" title="Next" rel="#002F6C,002F6C" id="PF_111" class="button" onclick="return false;"
style="width: 65px; height: 20px; z-index: 624; font-family: verdana; font-size: 10px; font-style: normal; color: rgb(251, 245, 245); left: 592px; top: 909px; border-style: solid; border-width: 1px; border-radius: 0px; border-color: rgb(0, 47, 108); overflow: hidden; text-overflow: ellipsis; white-space: nowrap; position: absolute; font-weight: bold !important; background: -webkit-linear-gradient(top, rgb(0, 47, 108), rgb(0, 47, 108)); display: block;">Next
</button>
<div id="PF_117" class="horizontalseparator" style="z-index: 216; left: 13px; top: 258px; width: 655px; height: 1px; background-color: rgb(173, 170, 170); display: block;">
</div>
<div id="PF_118" class="horizontalseparator" style="z-index: 667; left: 13px; top: 787px; width: 655px; height: 1px; background-color: rgb(173, 170, 170); display: block;">
</div>
<div id="PF_119" class="horizontalseparator" style="z-index: 626; left: 13px; top: 486px; width: 655px; height: 1px; background-color: rgb(173, 170, 170); display: block;">
</div>
<div id="PF_120" rel="False" class="typetext text text"
style="z-index: 217; color: rgb(157, 34, 53); font-family: verdana; font-size: 11px; font-style: normal; left: 17px; top: 240px; height: 14px; width: 233px; font-weight: bold !important; display: block;"> Employee (EE)/Location Information
</div>
<div id="PF_121" rel="False" class="typetext text text"
style="z-index: 670; color: rgb(157, 34, 53); font-family: verdana; font-size: 11px; font-style: normal; left: 17px; top: 768px; height: 14px; width: 203px; font-weight: bold !important; display: block;"> Contact </div>
<div id="PF_122" rel="False" class="typetext text text"
style="z-index: 627; color: rgb(157, 34, 53); font-family: verdana; font-size: 11px; font-style: normal; left: 17px; top: 466px; height: 14px; width: 203px; font-weight: bold !important; display: block;"> Case Information </div>
<div id="PF_123" rel="False" class="typetext text text" style="z-index: 127; font-family: verdana; font-size: 10px; font-style: normal; left: 18px; top: 619px; height: 20px; width: 424px; font-weight: bold !important; display: block;"> Are you
aware of being in contact with someone who has tested positive? </div><button aria-label="Button" title="Button" rel="#eeeeee,eeeeee" id="PF_124" class="button hidden" onclick="return false;"
style="width: 65px; height: 20px; z-index: 10; font-family: verdana; font-size: 10px; font-style: normal; left: 521px; top: 909px; border-style: solid; border-width: 1px; border-radius: 0px; border-color: rgb(0, 0, 0); overflow: hidden; text-overflow: ellipsis; white-space: nowrap; position: absolute; font-weight: normal !important; color: rgb(0, 0, 0); background: -webkit-linear-gradient(top, rgb(238, 238, 238), rgb(238, 238, 238)); display: none;">Button
</button>
<div id="PF_126div" class="timeinputContainer" style="width: 82px; height: 22px; left: 593px; top: 517px; z-index: 138; display: inline;">
<span class="timeEntry_wrap"><input type="text" id="PF_126" name="PF_126" class="timeinput hasTimeEntry"
style="font-family: verdana; font-size: 10px; font-style: normal; border-width: 1px; border-style: solid; z-index: 138; background-color: rgb(255, 255, 255); color: rgb(51, 51, 51); border-color: rgb(173, 170, 170); left: 593px; top: 517px; width: 45px; height: 18px; line-height: 18px; font-weight: normal !important; display: inline;"><span
class="timeEntry_control" style="display: inline-block; background: url('/PresentationServer/Content/images/spinnerUpDownnew.png') 0 0 no-repeat; width: 15px; height: 24px;"></span></span><label id="PF_126label" class="offscreen"
for="PF_126">Time Input 115</label>
</div><span><select id="PF_112" name="PF_112" class="dropdown" aria-label="test type drop down"
style="z-index: 142; font-family: verdana; font-size: 10px; font-style: normal; background-color: rgb(255, 255, 255); color: rgb(51, 51, 51); border-color: rgb(173, 170, 170); left: 555px; top: 545px; height: 20px; width: 107px; font-weight: normal !important; display: block;">
<option value=""></option>
<option value="2">At Home</option>
<option value="3">Clinical</option>
</select><label id="PF_112label" class="offscreen" for="PF_112">Selection</label></span><button aria-label="Search" title="Search" rel="#002F6C,002F6C" id="PF_127" class="button" onclick="return false;"
style="width: 65px; height: 20px; z-index: 10; font-family: verdana; font-size: 10px; font-style: normal; color: rgb(253, 252, 252); left: 21px; top: 424px; border-style: solid; border-width: 1px; border-radius: 0px; border-color: rgb(0, 47, 108); overflow: hidden; text-overflow: ellipsis; white-space: nowrap; position: absolute; font-weight: bold !important; background: -webkit-linear-gradient(top, rgb(0, 47, 108), rgb(0, 47, 108)); display: block;">Search
</button>
<div id="PF_131" rel="False" class="typetext text text" style="z-index: 11; font-family: verdana; font-size: 10px; font-style: normal; left: 35px; top: 404px; height: 21px; width: 615px; font-weight: normal !important; display: block;"> Use the
search button to find the applicable facility COVID contact; they will be sent a copy of this form upon submission. </div>
<div id="PF_132" rel="False" class="typetext text text" style="z-index: 12; font-family: verdana; font-size: 10px; font-style: normal; left: 473px; top: 426px; height: 14px; width: 35px; font-weight: bold !important; display: block;"> Email:
</div><span><input id="PF_130" name="PF_130" type="text" maxlength="99" value="" autocomplete="on" class="textinput" onclick="return false;"
style="font-family: verdana; font-size: 10px; font-style: normal; border-width: 1px; border-style: solid; z-index: 13; background-color: rgb(255, 255, 255); color: rgb(51, 51, 51); border-color: rgb(173, 170, 170); left: 514px; top: 424px; height: 16px; line-height: 16px; width: 140px; font-weight: normal !important; display: block;"
readonly=""><label id="PF_130label" class="offscreen" for="PF_130">loc contact email input</label></span>
<div id="PF_29" rel="False" class="typetext text text hidden" style="z-index: 165; font-family: verdana; font-size: 10px; font-style: normal; left: 20px; top: 645px; height: 14px; width: 180px; font-weight: bold !important; display: none;"> Was
this contact while at work? </div>
<div id="PF_22" rel="False" class="typetext text text hidden" style="z-index: 142; font-family: verdana; font-size: 10px; font-style: normal; left: 288px; top: 645px; height: 14px; width: 161px; font-weight: bold !important; display: none;">
Name of work contact: </div><span><input id="PF_23" name="PF_23" type="text" maxlength="99" value="" class="textinput hidden" onclick="return false;"
style="font-family: "sans-serif"; font-size: 10px; font-style: normal; border-width: 1px; border-style: solid; z-index: 700; background-color: rgb(255, 255, 255); color: rgb(51, 51, 51); border-color: rgb(173, 170, 170); left: 420px; top: 643px; height: 16px; line-height: 16px; width: 235px; font-weight: normal !important; display: none;"><label
id="PF_23label" class="offscreen" for="PF_23">exposed by input</label></span>
<div id="PF_27div" class="dateinputContainer" style="z-index: 176; left: 565px; top: 616px; display: none;">
<input id="PF_27" name="PF_27" type="text" readonly="readonly" class="dateinput hasDatepicker hidden" aria-label="exposure date input" data-validation-engine=" validate[funcCall[validFormatDate]] "
style="font-family: verdana; font-size: 10px; font-style: normal; border-width: 1px; border-style: solid; z-index: 176; background-color: rgb(255, 255, 255); color: rgb(0, 0, 0); border-color: rgb(173, 170, 170); width: 77px; font-weight: normal !important; display: none;"
alt=""><img class="ui-datepicker-trigger" src="/PresentationServer/Content/images/calendar.gif" alt="..." title="...">
</div>
<div id="PF_26" rel="False" class="typetext text text hidden" style="z-index: 177; font-family: verdana; font-size: 10px; font-style: normal; left: 531px; top: 619px; height: 14px; width: 30px; font-weight: bold !important; display: none;">
Date: </div>
<div id="PF_133" rel="False" class="smalltext text" style="z-index: 13; font-family: verdana; font-size: 8px; font-style: normal; left: 494px; top: 557px; height: 11px; width: 56px; font-weight: normal !important; display: block;"> (Select One)
</div>
<div id="PF_134" rel="False" class="smalltext text" style="z-index: 10; font-family: verdana; font-size: 8px; font-style: normal; left: 24px; top: 583px; height: 11px; width: 56px; font-weight: normal !important; display: block;"> (Select One)
</div><span><textarea id="PF_109" name="PF_109" maxlength="400" class="textarea hidden"
style="font-family: "sans-serif"; font-size: 10px; font-style: normal; border-width: 1px; border-style: solid; z-index: 192; background-color: rgb(255, 255, 255); color: rgb(51, 51, 51); border-color: rgb(173, 170, 170); left: 179px; top: 828px; height: 59px; width: 470px; overflow-x: hidden; font-weight: normal !important; display: none;"></textarea></span>
<div id="PF_108" rel="False" class="typetext text text hidden" style="z-index: 193; font-family: verdana; font-size: 10px; font-style: normal; left: 26px; top: 829px; height: 54px; width: 146px; font-weight: bold !important; display: none;">
Please provide the name(s) of the employee(s) that you feel meet the criteria above. </div><button aria-label="X close" title="X close" rel="#EEEEEE,EEEEEE" id="PF_135" class="button" onclick="return false;"
style="width: 65px; height: 22px; z-index: 286; font-family: verdana; font-size: 10px; font-style: normal; color: rgb(0, 0, 0); left: 605px; top: 9px; border-style: solid; border-width: 1px; border-radius: 0px; border-color: rgb(238, 238, 238); overflow: hidden; text-overflow: ellipsis; white-space: nowrap; position: absolute; font-weight: normal !important; background: -webkit-linear-gradient(top, rgb(238, 238, 238), rgb(238, 238, 238)); display: block;">X
close </button>
<fieldset id="PF_136Container" class="PageContainer" style="z-index:5;left:179px;top:647px;">
<div id="PF_136" name="PF_136" class="group"
style="width:150px;height:38px;background-color:#ffffff;border-width:1px;border-style: none;border-radius: 0px !important; behavior: url('https://app.perfectforms.com/pie.htc');text-indent:0px;border-color:#000000;">
<div id="PF_137div" class="radiobuttonContainer"
style="font-family: verdana; font-size: 10px; font-style: normal; z-index: 186; height: 18px; width: 60px; left: 10px; top: 20px; white-space: nowrap; text-overflow: ellipsis; font-weight: normal !important; display: inline;">
<input type="radio" name="PF_136" id="PF_137" value="Yes" class="radiobutton indivualRadio" tabindex="" aria-label="Yes" title="Yes" style="display: inline;"><label id="PF_137label" for="PF_137" style="width:38px;">Yes</label>
</div>
<div id="PF_138div" class="radiobuttonContainer"
style="font-family: verdana; font-size: 10px; font-style: normal; z-index: 186; height: 18px; width: 57px; left: 69px; top: 20px; white-space: nowrap; text-overflow: ellipsis; font-weight: normal !important; display: inline;">
<input type="radio" name="PF_136" id="PF_138" value="2" class="radiobutton indivualRadio" tabindex="" aria-label="No" title="No" style="display: inline;"><label id="PF_138label" for="PF_138" style="width:35px;">No</label>
</div>
</div>
</fieldset>
</div>
</div>
</form>Text Content
ee id inputphone number input Select OneAdminCommercialFinanceHRITLegalLogisticsOperations Selection Select OneBeverage & Dairy Foods HQBeverage & Dairy Foods PlantsCentral Area CouncilConsumer RetailCorporate HQDairy Brands HQDairy OneDFA FinancingDFA InsuranceEmpire LivestockFarm Services OperationsFarm Services & SustainabilityFarm SuppliesFluid NorthFluid SouthIce CreamIngredients HQIngredients PlantsMideast Area CouncilMilk Marketing HQMountain Area CouncilNortheast Area CouncilRisk ManagementSEMOSoutheast Area CouncilSouthwest Area CouncilWestern Area Council Selection Select OneBeverage & Dairy FoodsCorporateDairy BrandsFarm ServicesIngredient SolutionsMilk Marketing Selectionloc covid contact input name I am sick (potential COVID-19 symptoms)I was exposed to a COVID-19 positive person Selection Released: Date Admitted: ID: rep location inputlocation input Yes No Yes No Yes No job title input PositiveNegativeIn progressNo test/won't test SelectionEE name Name: Phone #: Date of Results: Job Title: When were you last present at a company facility/company function? Test Type: Test Date: Test Results: Has a COVID-19 test been completed? Button Have you been hospitalized? Symptoms first began? Reason for report? (Please select one) Have you experienced any symptoms? City, State: City, State: Reporting Location: Location: Please provide a brief summary of the situation. Text Input 17 Yes No Enter your employee ID below or use the button to search for it. You may search by first name, last name, email or a portion of one of these. Text Input 17Text Input 17Search rep loc city, state inputloc city state input Date of Notice: time of notification input Time: Function: BU: Division: Facility COVID Contact: Time: Max 200 characters Were you WITHIN 6 FEET OF OTHER EMPLOYEES FOR MORE THAN 15 MINUTES OVER A 24 HOUR PERIOD within 48 hours of symptom onset. Yes No Next Employee (EE)/Location Information Contact Case Information Are you aware of being in contact with someone who has tested positive? Button Time Input 115 At HomeClinical SelectionSearch Use the search button to find the applicable facility COVID contact; they will be sent a copy of this form upon submission. Email: loc contact email input Was this contact while at work? Name of work contact: exposed by input Date: (Select One) (Select One) Please provide the name(s) of the employee(s) that you feel meet the criteria above. X close Yes No Loading hide Opening app... TOOLTIP PrevNext JanFebMarAprMayJunJulAugSepOctNovDec190019011902190319041905190619071908190919101911191219131914191519161917191819191920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025202620272028202920302031203220332034203520362037203820392040204120422043204420452046204720482049205020512052205320542055205620572058205920602061206220632064206520662067206820692070207120722073207420752076207720782079208020812082208320842085208620872088208920902091209220932094209520962097209820992100 SuMoTuWeThFrSa 1234567891011121314151617181920212223242526272829