Covid Contact Submitted By*Restaurant*Pick OnePacific Ave #802Wilson Way #969Lower Sacramento Road #3017Lodi Avenue #3580Charter Way #4111Tracy Blvd #4147Ben Holt #4643Elk Grove Blvd #4804Center Street #6216Waterloo Road #7058Louise #8195Floyd #10338Kettleman Lane/99 #10555Galt #10852March Ln. & West Ln. #1179711th Street #12264Martell #13329Westley #13556Flag City #14444Laguna #17476Patterson #17477Riverbank #17936Holman Road #20612Scenic #22222Union Road #23653Don Avenue #24092Gateway #25489Quail Lakes #25768Laguna Springs #26345Calvine #26895ValPico #32054Spanos Park #32074Daniels Street #32116Lathrop Road #32765Twin Cities #34891Yosemite #35025Bruceville #35050Elk Grove-Florin #35797Sheldon #35911Tracy High #36229Sunwest #36681Reynolds Ranch #40627Weston Ranch #40735GSRG #1000Employee Name* First Last Employee Phone Number*Employee Email* Last Date Worked* MM slash DD slash YYYY Was the employee told to complete the COVID Questionnaire?* Yes No The COVID Questionnaire can be found at goldenstatemcd.com/covidWas the employee asked to go home?* Yes No Who told the employee to go home?* First Last When was the employee told to go home?* MM slash DD slash YYYY What time was the employee told to go home?* : Hours Minutes AM PM AM/PM Is the employee experiencing COVID related symptoms?* Yes No Unsure Do you know when the employee began experiencing COVID related symptoms?* Yes No When did the symptoms start?* MM slash DD slash YYYY Does the employee believe he/she was exposed to COVID?* Yes No Unsure Does the employee live with someone who has tested positive for COVID?* Yes No Unsure Do you know when the employee was last exposed to COVID?* Yes No When was the employee last exposed?* MM slash DD slash YYYY Has the employee been tested for COVID?* Yes, tested negative Yes, tested positive Yes, waiting on results No, is scheduled to test No, will be scheduled in the future No, will not be testing Date Test is Scheduled* MM slash DD slash YYYY Date Test was Taken* MM slash DD slash YYYY Please upload test results if you have themMax. file size: 300 MB.Is the employee fully vaccinated?* Yes No Unknown The CDC considers someone fully vaccinated if it has been 14 or more days since their second shot.Any additional detail you would like to provide:
