Contagious Illness Report Form for Lakeridge Health Colleagues

Name:

What site do you work at?

Ajax Pickering

Bowmanville

Oshawa

Port Perry

Whitby

Other, please Specify

Department:

Department worked in last:

Last day worked:

Contact Phone number:

Date of onset of symptoms:

Any family members/household contacts Ill with the same symptoms?

Please provide your symptoms.

Vomiting

Diarrhea

Nausea

Cough

Congestion

Fever

Malaise

Sore Throat

Additional Comments