Employee COVID-19 Self Reporting Notice

Also review the District’s Injury and Illness Prevention Program (IIPP). For question contact Environmental Health & Safety/Risk Management (EH&S/RM).

COVID-19 Self-Reporting Notice

Effective February 3, 2025, the California Division of Occupational Safety and Health (Cal/OSHA) will sunset most of its COVID-19 prevention regulations. While certain requirements are sunsetting, the recordkeeping provisions will remain in effect until February 3, 2026. The District remains committed to prioritizing the health and well-being of our employees under the District’s Injury and Illness Prevention Program (IIPP) while also adhering to the updated regulations.

First and Last Name of Individual Reporting A Positive COVID-19 Test*
Employee ID#
If a Palomar Employee, list your Palomar ID #.
Contact Phone*
Email*

List your contact email address.
Affiliation*
- Employee
- Other
Job Title/Position*
Work Site Location*
Campus, Building and/or room number
Date of Positive Test*
MM slash DD slash YYYY
Are you exhibiting any COVID-like symptoms?*
- Yes
- No
Some examples may include: Fever or chills, Cough, Shortness of breath or difficulty breathing, Fatigue, Muscle or body aches, Headache, New loss of taste or smell, Sore throat Congestion or runny nose Nausea or vomiting Diarrhea
Date of Symptom On-Set*
MM slash DD slash YYYY
When were you last on campus or at an education center?*
MM slash DD slash YYYY

Coronavirus (COVID-19) Resources & Updates

Coronavirus (COVID-19) Resources & Updates

COVID-19 Self-Reporting Notice

Contact Information

Environmental Health & Safety

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