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Please complete this form for each staff member who has been physically displaced from their typical work area pursuant to recommendations regarding COVID-19.
What division does the employee work under?
Enter a number
Indicate if the employee falls under any of these categories classified as providing critical life-safety services:
Status of ability to perform essential functions
Additional comments about this employee that could be helpful for tracking purposes. Also specify what type of leave if "Other" was selected above.
This field is not part of the form submission.
* indicates a required field