COVID-19 EMPLOYEE EXPOSURE

This is form is used regardless of symptoms due to a known exposure to a confirmed COVID-19.
 
If you need to complete a Leave Request Form, please go to the Employee Section and select the Leave Request Form.

You may have been exposed to COVID-19 in your community. 

Contact Human Resources at 800-249-6161 or humanresources@mjsia.com regarding any changes or questions.

EMPLOYEE QUESTIONNAIRE

Were you exposed to a confirmed positive COVID-19 case? *
If you were not exposed to a confirmed postiive COVID-19 case, this is the incorrect form to be completing.  Please contact Human Resources at 319-393-6162 . 800-249-6161 or email humanresources@mjsia.com for further directions.
Do you work with other MJS employees or client individuals in your assigned facility / facilities? *
Do you work during the assigned facility's normal business hours while the client is present? *
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Have you been vaccinated for COVID-19? *
Have you provided your vaccination card to Human Resources?

Have you been quarantined for COVID-19 exposure? *
Were you tested for COVID-19? *
Do you know the test results? *
Was the COVID-19 test positive? *
Did you develop any symptoms? *

EMPLOYEE ACKNOWLEDGMENT

I agree that the information I am providing is true and accurate to the best of my knowledge.

Signature: *
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