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COVID-19 Contact Tracing Exception Form

In order to respond as quickly as possible to a potential or known workplace exposure to the COVID-19 virus, [Company name] requires all employees to complete this form in an ongoing manner until further notice. Please work with your manager to determine who your expected contacts are while at work (team members, coworkers in other departments, clients, etc.) and which areas you are expected to be in (which floor of the building or work area, conference rooms, break rooms, or which limited movement plan your team may be assigned to for exposure control purposes).

On a daily basis, please enter any exceptions to your expected contacts or contact areas you have visited in the workplace. If there are none, please leave blank. This information must be kept on a rolling 14-day basis [or enter other duration]. Your manager will discuss with you how and where to save this information so he or she has access to it.

[Company name] greatly appreciates your attention to this daily task to help keep our workers safe. Please contact your manager or HR with any questions you may have.

Employee NameJob Title
DepartmentManager Name


Expected Contacts
(Examples: all marketing team members (listed) or all in-house team members (listed); Arancha Gonzales/finance; Kate Horowitz, ABC company client.)


Expected Contact Areas
(Examples: subject to Safety/Limited Movement Plan #1; third floor, SW corner; third floor break room and restrooms; manufacturing floor area #2.)


DateException Details
 (Examples: meeting in 2nd floor conference room; Kareem Abudi, Kate Hanson.)



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