Re: Pan/Flu Biz Continuity Guide & Template
<TABLE class=MsoNormalTable style="BACKGROUND: #0c0c0c; MARGIN: auto 6.75pt; WIDTH: 6.65in; BORDER-COLLAPSE: collapse; mso-padding-alt: 0in 5.4pt 0in 5.4pt; mso-table-lspace: 9.0pt; mso-table-rspace: 9.0pt; mso-table-anchor-vertical: paragraph; mso-table-anchor-horizontal: margin; mso-table-left: 5.35pt; mso-table-top: .05pt" cellSpacing=0 cellPadding=0 width=638 align=left border=0><TBODY><TR style="mso-yfti-irow: 0; mso-yfti-lastrow: yes"><TD style="BORDER-RIGHT: #ece9d8; PADDING-RIGHT: 5.4pt; BORDER-TOP: #ece9d8; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0in; BORDER-LEFT: #ece9d8; WIDTH: 6.65in; PADDING-TOP: 0in; BORDER-BOTTOM: #ece9d8; BACKGROUND-COLOR: transparent" vAlign=top width=638>Annex 6: Management of Ill Employees <?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
</TD></TR></TBODY></TABLE>
<o:p></o:p>
Restrict Workplace Entry of People with Influenza Symptoms<o:p></o:p>
<o:p></o:p>
During an influenza pandemic an effective way to limit the spread of disease is to ask infected individuals to remain home. During Stage 3-5 (Respond) the [Organization] will:<o:p></o:p>
<o:p></o:p>
1. Notify employees they should not come to work if they are unwell, particularly if they are exhibiting any influenza symptoms.<o:p></o:p>
2. Post notices at all workplace/facility entry points advising staff and visitors not to enter if they have influenza symptoms. <o:p></o:p>
3. Advise employees to call the Organization?s health and safety staff if they become ill at home or work (provide a designated phone number for reporting illness).<o:p></o:p>
4. Provide health and safety staff with protocol for employees who become ill (attached). <o:p></o:p>
5. Ensure that ill employees have completed the required isolation period (guidance to be provided by the San Francisco Department of Public Health) and are healthy and no longer infectiousbefore allowing them to return to work. Note that staff who have recovered from the pandemic influenza are less likely to be re-infected and should be encouraged to return to work. <o:p></o:p>
<o:p></o:p>
Protocol for employees who become Ill
<o:p></o:p>
<o:p></o:p>
Advise employees that if a person feels ill, or if someone observes that another person is exhibiting symptoms of influenza at work, they are to contact their manager or other designated person. Telephone communications are preferable.<o:p></o:p>
<o:p></o:p>
Duties of health and safety staff: <o:p></o:p>
<o:p></o:p>
1. Speak with the individual by phone.<o:p></o:p>
2. Check if the employee has any influenza symptoms. (The San Francisco Health Department will provide a list of symptoms). <o:p></o:p>
? If the employee does not have any symptoms they are unlikely to have influenza and should be reassured and advised to call again later or to see their doctor if they are still concerned. <o:p></o:p>
? If the employee has influenza symptoms they should be treated as a ?suspect influenza case.? <o:p></o:p>
3. Complete a Suspect Influenza Case Form (attached). <o:p></o:p>
4. If the employee is at work provide them with a surgical mask and instruct them to put the mask on immediately. (This is to help protect other staff.). <o:p></o:p>
? Instruct employee to leave work. If possible, public transportation should be avoided. If public transportation is unavoidable, instruct the employee to keep the mask on and cough or sneeze into a tissue while traveling.<o:p></o:p>
5. Advise the employee to contact a health professional. This may involve phoning the person?s normal doctor or a specially designated center to seek advice.<o:p></o:p>
6. Advise the employee on how long to stay away from work (the San Francisco Department of Public Health website, www.sfdph.org/cdcp, will post isolation guidance).<o:p></o:p>
7. Have the employee?s work station cleaned and disinfected as indicated in Annex 10: Workplace Cleaning.<o:p></o:p>
8. The San Francisco Health Department may ask employers to 1) identify contacts (once an employee is suspected to be infected); 2) advise contacts that they have been in contact with a person suspected of having influenza; and/or 3) ask contacts to go home, and stay home until advised otherwise.<o:p></o:p>
9. Advise supervisor and human resources of employee absence and need for cover.<o:p></o:p>
10. Check on the employee during his/her absence from work.<o:p></o:p>
11. Encourage employees to return to work once they have recovered.<o:p></o:p>
<o:p></o:p>
Details of affected employee<o:p></o:p>
<o:p></o:p>
<TABLE class=MsoNormalTable style="BORDER-RIGHT: medium none; BORDER-TOP: medium none; BORDER-LEFT: medium none; WIDTH: 6.7in; BORDER-BOTTOM: medium none; BORDER-COLLAPSE: collapse; mso-padding-alt: 0in 5.4pt 0in 5.4pt; mso-border-alt: solid windowtext .5pt; mso-border-insideh: .5pt solid windowtext; mso-border-insidev: .5pt solid windowtext" cellSpacing=0 cellPadding=0 width=643 border=1><TBODY><TR style="mso-yfti-irow: 0; page-break-inside: avoid"><TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: windowtext 1pt solid; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0in; BORDER-LEFT: windowtext 1pt solid; WIDTH: 2.2in; PADDING-TOP: 0in; BORDER-BOTTOM: windowtext 1pt solid; BACKGROUND-COLOR: transparent; mso-border-alt: solid windowtext .5pt" vAlign=top width=211>Name:<o:p></o:p>
<o:p> </o:p>
<o:p> </o:p>
</TD><TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: windowtext 1pt solid; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0in; BORDER-LEFT: #ece9d8; WIDTH: 96.65pt; PADDING-TOP: 0in; BORDER-BOTTOM: windowtext 1pt solid; BACKGROUND-COLOR: transparent; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt" vAlign=top width=129>Date:<o:p></o:p>
</TD><TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: windowtext 1pt solid; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0in; BORDER-LEFT: #ece9d8; WIDTH: 101.35pt; PADDING-TOP: 0in; BORDER-BOTTOM: windowtext 1pt solid; BACKGROUND-COLOR: transparent; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt" vAlign=top width=135 colSpan=2>q Visitor<o:p></o:p>
q Employee<o:p></o:p>
</TD><TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: windowtext 1pt solid; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0in; BORDER-LEFT: #ece9d8; WIDTH: 1.75in; PADDING-TOP: 0in; BORDER-BOTTOM: windowtext 1pt solid; BACKGROUND-COLOR: transparent; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt" vAlign=top width=168>Date of Birth:<o:p></o:p>
</TD></TR><TR style="mso-yfti-irow: 1"><TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: #ece9d8; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0in; BORDER-LEFT: windowtext 1pt solid; WIDTH: 2.2in; PADDING-TOP: 0in; BORDER-BOTTOM: windowtext 1pt solid; BACKGROUND-COLOR: transparent; mso-border-top-alt: solid windowtext .5pt; mso-border-alt: solid windowtext .5pt" vAlign=top width=211>Job Title:<o:p></o:p>
<o:p> </o:p>
<o:p> </o:p>
</TD><TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: #ece9d8; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0in; BORDER-LEFT: #ece9d8; WIDTH: 2in; PADDING-TOP: 0in; BORDER-BOTTOM: windowtext 1pt solid; BACKGROUND-COLOR: transparent; mso-border-top-alt: solid windowtext .5pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt" vAlign=top width=192 colSpan=2>Worksite:<o:p></o:p>
</TD><TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: #ece9d8; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0in; BORDER-LEFT: #ece9d8; WIDTH: 2.5in; PADDING-TOP: 0in; BORDER-BOTTOM: windowtext 1pt solid; BACKGROUND-COLOR: transparent; mso-border-top-alt: solid windowtext .5pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt" vAlign=top width=240 colSpan=2>Location of Isolation:<o:p></o:p>
</TD></TR><TR style="mso-yfti-irow: 2; page-break-inside: avoid"><TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: #ece9d8; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0in; BORDER-LEFT: windowtext 1pt solid; WIDTH: 6.7in; PADDING-TOP: 0in; BORDER-BOTTOM: windowtext 1pt solid; BACKGROUND-COLOR: transparent; mso-border-top-alt: solid windowtext .5pt; mso-border-alt: solid windowtext .5pt" vAlign=top width=643 colSpan=5>Address:<o:p></o:p>
<o:p> </o:p>
<o:p> </o:p>
</TD></TR><TR style="mso-yfti-irow: 3; page-break-inside: avoid"><TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: #ece9d8; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0in; BORDER-LEFT: windowtext 1pt solid; WIDTH: 6.7in; PADDING-TOP: 0in; BORDER-BOTTOM: windowtext 1pt solid; BACKGROUND-COLOR: transparent; mso-border-top-alt: solid windowtext .5pt; mso-border-alt: solid windowtext .5pt" vAlign=top width=643 colSpan=5>Telephone no:<o:p></o:p>
<o:p> </o:p>
____________________ (Work) ____________________ (Home) ____________________ (Other)<o:p></o:p>
<o:p> </o:p>
</TD></TR><TR style="mso-yfti-irow: 4; page-break-inside: avoid"><TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: #ece9d8; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0in; BORDER-LEFT: windowtext 1pt solid; WIDTH: 6.7in; PADDING-TOP: 0in; BORDER-BOTTOM: windowtext 1pt solid; BACKGROUND-COLOR: transparent; mso-border-top-alt: solid windowtext .5pt; mso-border-alt: solid windowtext .5pt" vAlign=top width=643 colSpan=5>Symptoms noticed:<o:p></o:p>
<o:p> </o:p>
q Fever Time of fever on-set: _________________________<o:p></o:p>
q Headache <o:p></o:p>
q Dry cough Time of isolation: ____________________________<o:p></o:p>
q Cold<o:p></o:p>
q Body aches Date expected to return to work: _______________<o:p></o:p>
q Fatigue<o:p></o:p>
q Other: _____________________<o:p></o:p>
<o:p></o:p>
* Symptoms and isolation periods will be updated by the San Francisco Health Department as information becomes available following the emergence of a pandemic influenza virus strain. Check www.sfdph.org/cdcp. <o:p></o:p>
<o:p> </o:p>
</TD></TR><TR style="mso-yfti-irow: 5; page-break-inside: avoid"><TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: #ece9d8; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0in; BORDER-LEFT: windowtext 1pt solid; WIDTH: 6.7in; PADDING-TOP: 0in; BORDER-BOTTOM: windowtext 1pt solid; BACKGROUND-COLOR: transparent; mso-border-top-alt: solid windowtext .5pt; mso-border-alt: solid windowtext .5pt" vAlign=top width=643 colSpan=5>Where referred:<o:p></o:p>
<o:p> </o:p>
</TD></TR><TR style="mso-yfti-irow: 6; mso-yfti-lastrow: yes; page-break-inside: avoid"><TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: #ece9d8; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0in; BORDER-LEFT: windowtext 1pt solid; WIDTH: 6.7in; PADDING-TOP: 0in; BORDER-BOTTOM: windowtext 1pt solid; BACKGROUND-COLOR: transparent; mso-border-top-alt: solid windowtext .5pt; mso-border-alt: solid windowtext .5pt" vAlign=top width=643 colSpan=5>Notes:<o:p></o:p>
<o:p> </o:p>
<o:p> </o:p>
</TD></TR><TR height=0><TD style="BORDER-RIGHT: #ece9d8; BORDER-TOP: #ece9d8; BORDER-LEFT: #ece9d8; BORDER-BOTTOM: #ece9d8; BACKGROUND-COLOR: transparent" width=211></TD><TD style="BORDER-RIGHT: #ece9d8; BORDER-TOP: #ece9d8; BORDER-LEFT: #ece9d8; BORDER-BOTTOM: #ece9d8; BACKGROUND-COLOR: transparent" width=129></TD><TD style="BORDER-RIGHT: #ece9d8; BORDER-TOP: #ece9d8; BORDER-LEFT: #ece9d8; BORDER-BOTTOM: #ece9d8; BACKGROUND-COLOR: transparent" width=63></TD><TD style="BORDER-RIGHT: #ece9d8; BORDER-TOP: #ece9d8; BORDER-LEFT: #ece9d8; BORDER-BOTTOM: #ece9d8; BACKGROUND-COLOR: transparent" width=72></TD><TD style="BORDER-RIGHT: #ece9d8; BORDER-TOP: #ece9d8; BORDER-LEFT: #ece9d8; BORDER-BOTTOM: #ece9d8; BACKGROUND-COLOR: transparent" width=168></TD></TR></TBODY></TABLE>
<o:p></o:p>
Details of Reporter<o:p></o:p>
<o:p></o:p>
<TABLE class=MsoNormalTable style="BORDER-RIGHT: medium none; BORDER-TOP: medium none; BORDER-LEFT: medium none; WIDTH: 6.7in; BORDER-BOTTOM: medium none; BORDER-COLLAPSE: collapse; mso-padding-alt: 0in 5.4pt 0in 5.4pt; mso-border-alt: solid windowtext .5pt; mso-border-insideh: .5pt solid windowtext; mso-border-insidev: .5pt solid windowtext" cellSpacing=0 cellPadding=0 width=643 border=1><TBODY><TR style="mso-yfti-irow: 0"><TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: windowtext 1pt solid; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0in; BORDER-LEFT: windowtext 1pt solid; WIDTH: 6.7in; PADDING-TOP: 0in; BORDER-BOTTOM: windowtext 1pt solid; BACKGROUND-COLOR: transparent; mso-border-alt: solid windowtext .5pt" vAlign=top width=643>Name:<o:p></o:p>
<o:p> </o:p>
</TD></TR><TR style="mso-yfti-irow: 1"><TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: #ece9d8; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0in; BORDER-LEFT: windowtext 1pt solid; WIDTH: 6.7in; PADDING-TOP: 0in; BORDER-BOTTOM: windowtext 1pt solid; BACKGROUND-COLOR: transparent; mso-border-top-alt: solid windowtext .5pt; mso-border-alt: solid windowtext .5pt" vAlign=top width=643>Job title:<o:p></o:p>
<o:p> </o:p>
</TD></TR><TR style="mso-yfti-irow: 2; mso-yfti-lastrow: yes"><TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: #ece9d8; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0in; BORDER-LEFT: windowtext 1pt solid; WIDTH: 6.7in; PADDING-TOP: 0in; BORDER-BOTTOM: windowtext 1pt solid; BACKGROUND-COLOR: transparent; mso-border-top-alt: solid windowtext .5pt; mso-border-alt: solid windowtext .5pt" vAlign=top width=643>Telephone no.:<o:p></o:p>
<o:p> </o:p>
____________________ (Work) ____________________ (Home) ____________________ (Other)<o:p></o:p>
<o:p> </o:p>
</TD></TR></TBODY></TABLE>
<o:p></o:p>
<TABLE class=MsoNormalTable style="BACKGROUND: #0c0c0c; MARGIN: auto 6.75pt; WIDTH: 6.65in; BORDER-COLLAPSE: collapse; mso-padding-alt: 0in 5.4pt 0in 5.4pt; mso-table-lspace: 9.0pt; mso-table-rspace: 9.0pt; mso-table-anchor-vertical: paragraph; mso-table-anchor-horizontal: margin; mso-table-left: 5.35pt; mso-table-top: .05pt" cellSpacing=0 cellPadding=0 width=638 align=left border=0><TBODY><TR style="mso-yfti-irow: 0; mso-yfti-lastrow: yes"><TD style="BORDER-RIGHT: #ece9d8; PADDING-RIGHT: 5.4pt; BORDER-TOP: #ece9d8; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0in; BORDER-LEFT: #ece9d8; WIDTH: 6.65in; PADDING-TOP: 0in; BORDER-BOTTOM: #ece9d8; BACKGROUND-COLOR: transparent" vAlign=top width=638>Annex 6: Management of Ill Employees <?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p>
</TD></TR></TBODY></TABLE>
<o:p></o:p>
Restrict Workplace Entry of People with Influenza Symptoms<o:p></o:p>
<o:p></o:p>
During an influenza pandemic an effective way to limit the spread of disease is to ask infected individuals to remain home. During Stage 3-5 (Respond) the [Organization] will:<o:p></o:p>
<o:p></o:p>
1. Notify employees they should not come to work if they are unwell, particularly if they are exhibiting any influenza symptoms.<o:p></o:p>
2. Post notices at all workplace/facility entry points advising staff and visitors not to enter if they have influenza symptoms. <o:p></o:p>
3. Advise employees to call the Organization?s health and safety staff if they become ill at home or work (provide a designated phone number for reporting illness).<o:p></o:p>
4. Provide health and safety staff with protocol for employees who become ill (attached). <o:p></o:p>
5. Ensure that ill employees have completed the required isolation period (guidance to be provided by the San Francisco Department of Public Health) and are healthy and no longer infectiousbefore allowing them to return to work. Note that staff who have recovered from the pandemic influenza are less likely to be re-infected and should be encouraged to return to work. <o:p></o:p>
<o:p></o:p>
Protocol for employees who become Ill
<o:p></o:p>
- Draft -<o:p></o:p>
Advise employees that if a person feels ill, or if someone observes that another person is exhibiting symptoms of influenza at work, they are to contact their manager or other designated person. Telephone communications are preferable.<o:p></o:p>
<o:p></o:p>
Duties of health and safety staff: <o:p></o:p>
<o:p></o:p>
1. Speak with the individual by phone.<o:p></o:p>
2. Check if the employee has any influenza symptoms. (The San Francisco Health Department will provide a list of symptoms). <o:p></o:p>
? If the employee does not have any symptoms they are unlikely to have influenza and should be reassured and advised to call again later or to see their doctor if they are still concerned. <o:p></o:p>
? If the employee has influenza symptoms they should be treated as a ?suspect influenza case.? <o:p></o:p>
3. Complete a Suspect Influenza Case Form (attached). <o:p></o:p>
4. If the employee is at work provide them with a surgical mask and instruct them to put the mask on immediately. (This is to help protect other staff.). <o:p></o:p>
? Instruct employee to leave work. If possible, public transportation should be avoided. If public transportation is unavoidable, instruct the employee to keep the mask on and cough or sneeze into a tissue while traveling.<o:p></o:p>
5. Advise the employee to contact a health professional. This may involve phoning the person?s normal doctor or a specially designated center to seek advice.<o:p></o:p>
6. Advise the employee on how long to stay away from work (the San Francisco Department of Public Health website, www.sfdph.org/cdcp, will post isolation guidance).<o:p></o:p>
7. Have the employee?s work station cleaned and disinfected as indicated in Annex 10: Workplace Cleaning.<o:p></o:p>
8. The San Francisco Health Department may ask employers to 1) identify contacts (once an employee is suspected to be infected); 2) advise contacts that they have been in contact with a person suspected of having influenza; and/or 3) ask contacts to go home, and stay home until advised otherwise.<o:p></o:p>
9. Advise supervisor and human resources of employee absence and need for cover.<o:p></o:p>
10. Check on the employee during his/her absence from work.<o:p></o:p>
11. Encourage employees to return to work once they have recovered.<o:p></o:p>
<o:p> </o:p>
<o:p> </o:p>
<o:p> </o:p>
<o:p> </o:p>
SUSPECT INFLUENZA CASE FORM<o:p></o:p>
For Management of Staff who become ill at work<o:p></o:p>
Details of affected employee<o:p></o:p>
<o:p></o:p>
<TABLE class=MsoNormalTable style="BORDER-RIGHT: medium none; BORDER-TOP: medium none; BORDER-LEFT: medium none; WIDTH: 6.7in; BORDER-BOTTOM: medium none; BORDER-COLLAPSE: collapse; mso-padding-alt: 0in 5.4pt 0in 5.4pt; mso-border-alt: solid windowtext .5pt; mso-border-insideh: .5pt solid windowtext; mso-border-insidev: .5pt solid windowtext" cellSpacing=0 cellPadding=0 width=643 border=1><TBODY><TR style="mso-yfti-irow: 0; page-break-inside: avoid"><TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: windowtext 1pt solid; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0in; BORDER-LEFT: windowtext 1pt solid; WIDTH: 2.2in; PADDING-TOP: 0in; BORDER-BOTTOM: windowtext 1pt solid; BACKGROUND-COLOR: transparent; mso-border-alt: solid windowtext .5pt" vAlign=top width=211>Name:<o:p></o:p>
<o:p> </o:p>
<o:p> </o:p>
</TD><TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: windowtext 1pt solid; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0in; BORDER-LEFT: #ece9d8; WIDTH: 96.65pt; PADDING-TOP: 0in; BORDER-BOTTOM: windowtext 1pt solid; BACKGROUND-COLOR: transparent; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt" vAlign=top width=129>Date:<o:p></o:p>
</TD><TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: windowtext 1pt solid; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0in; BORDER-LEFT: #ece9d8; WIDTH: 101.35pt; PADDING-TOP: 0in; BORDER-BOTTOM: windowtext 1pt solid; BACKGROUND-COLOR: transparent; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt" vAlign=top width=135 colSpan=2>q Visitor<o:p></o:p>
q Employee<o:p></o:p>
</TD><TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: windowtext 1pt solid; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0in; BORDER-LEFT: #ece9d8; WIDTH: 1.75in; PADDING-TOP: 0in; BORDER-BOTTOM: windowtext 1pt solid; BACKGROUND-COLOR: transparent; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt" vAlign=top width=168>Date of Birth:<o:p></o:p>
</TD></TR><TR style="mso-yfti-irow: 1"><TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: #ece9d8; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0in; BORDER-LEFT: windowtext 1pt solid; WIDTH: 2.2in; PADDING-TOP: 0in; BORDER-BOTTOM: windowtext 1pt solid; BACKGROUND-COLOR: transparent; mso-border-top-alt: solid windowtext .5pt; mso-border-alt: solid windowtext .5pt" vAlign=top width=211>Job Title:<o:p></o:p>
<o:p> </o:p>
<o:p> </o:p>
</TD><TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: #ece9d8; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0in; BORDER-LEFT: #ece9d8; WIDTH: 2in; PADDING-TOP: 0in; BORDER-BOTTOM: windowtext 1pt solid; BACKGROUND-COLOR: transparent; mso-border-top-alt: solid windowtext .5pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt" vAlign=top width=192 colSpan=2>Worksite:<o:p></o:p>
</TD><TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: #ece9d8; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0in; BORDER-LEFT: #ece9d8; WIDTH: 2.5in; PADDING-TOP: 0in; BORDER-BOTTOM: windowtext 1pt solid; BACKGROUND-COLOR: transparent; mso-border-top-alt: solid windowtext .5pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt" vAlign=top width=240 colSpan=2>Location of Isolation:<o:p></o:p>
</TD></TR><TR style="mso-yfti-irow: 2; page-break-inside: avoid"><TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: #ece9d8; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0in; BORDER-LEFT: windowtext 1pt solid; WIDTH: 6.7in; PADDING-TOP: 0in; BORDER-BOTTOM: windowtext 1pt solid; BACKGROUND-COLOR: transparent; mso-border-top-alt: solid windowtext .5pt; mso-border-alt: solid windowtext .5pt" vAlign=top width=643 colSpan=5>Address:<o:p></o:p>
<o:p> </o:p>
<o:p> </o:p>
</TD></TR><TR style="mso-yfti-irow: 3; page-break-inside: avoid"><TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: #ece9d8; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0in; BORDER-LEFT: windowtext 1pt solid; WIDTH: 6.7in; PADDING-TOP: 0in; BORDER-BOTTOM: windowtext 1pt solid; BACKGROUND-COLOR: transparent; mso-border-top-alt: solid windowtext .5pt; mso-border-alt: solid windowtext .5pt" vAlign=top width=643 colSpan=5>Telephone no:<o:p></o:p>
<o:p> </o:p>
____________________ (Work) ____________________ (Home) ____________________ (Other)<o:p></o:p>
<o:p> </o:p>
</TD></TR><TR style="mso-yfti-irow: 4; page-break-inside: avoid"><TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: #ece9d8; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0in; BORDER-LEFT: windowtext 1pt solid; WIDTH: 6.7in; PADDING-TOP: 0in; BORDER-BOTTOM: windowtext 1pt solid; BACKGROUND-COLOR: transparent; mso-border-top-alt: solid windowtext .5pt; mso-border-alt: solid windowtext .5pt" vAlign=top width=643 colSpan=5>Symptoms noticed:<o:p></o:p>
<o:p> </o:p>
q Fever Time of fever on-set: _________________________<o:p></o:p>
q Headache <o:p></o:p>
q Dry cough Time of isolation: ____________________________<o:p></o:p>
q Cold<o:p></o:p>
q Body aches Date expected to return to work: _______________<o:p></o:p>
q Fatigue<o:p></o:p>
q Other: _____________________<o:p></o:p>
<o:p></o:p>
* Symptoms and isolation periods will be updated by the San Francisco Health Department as information becomes available following the emergence of a pandemic influenza virus strain. Check www.sfdph.org/cdcp. <o:p></o:p>
<o:p> </o:p>
</TD></TR><TR style="mso-yfti-irow: 5; page-break-inside: avoid"><TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: #ece9d8; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0in; BORDER-LEFT: windowtext 1pt solid; WIDTH: 6.7in; PADDING-TOP: 0in; BORDER-BOTTOM: windowtext 1pt solid; BACKGROUND-COLOR: transparent; mso-border-top-alt: solid windowtext .5pt; mso-border-alt: solid windowtext .5pt" vAlign=top width=643 colSpan=5>Where referred:<o:p></o:p>
<o:p> </o:p>
</TD></TR><TR style="mso-yfti-irow: 6; mso-yfti-lastrow: yes; page-break-inside: avoid"><TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: #ece9d8; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0in; BORDER-LEFT: windowtext 1pt solid; WIDTH: 6.7in; PADDING-TOP: 0in; BORDER-BOTTOM: windowtext 1pt solid; BACKGROUND-COLOR: transparent; mso-border-top-alt: solid windowtext .5pt; mso-border-alt: solid windowtext .5pt" vAlign=top width=643 colSpan=5>Notes:<o:p></o:p>
<o:p> </o:p>
<o:p> </o:p>
</TD></TR><TR height=0><TD style="BORDER-RIGHT: #ece9d8; BORDER-TOP: #ece9d8; BORDER-LEFT: #ece9d8; BORDER-BOTTOM: #ece9d8; BACKGROUND-COLOR: transparent" width=211></TD><TD style="BORDER-RIGHT: #ece9d8; BORDER-TOP: #ece9d8; BORDER-LEFT: #ece9d8; BORDER-BOTTOM: #ece9d8; BACKGROUND-COLOR: transparent" width=129></TD><TD style="BORDER-RIGHT: #ece9d8; BORDER-TOP: #ece9d8; BORDER-LEFT: #ece9d8; BORDER-BOTTOM: #ece9d8; BACKGROUND-COLOR: transparent" width=63></TD><TD style="BORDER-RIGHT: #ece9d8; BORDER-TOP: #ece9d8; BORDER-LEFT: #ece9d8; BORDER-BOTTOM: #ece9d8; BACKGROUND-COLOR: transparent" width=72></TD><TD style="BORDER-RIGHT: #ece9d8; BORDER-TOP: #ece9d8; BORDER-LEFT: #ece9d8; BORDER-BOTTOM: #ece9d8; BACKGROUND-COLOR: transparent" width=168></TD></TR></TBODY></TABLE>
<o:p></o:p>
Details of Reporter<o:p></o:p>
<o:p></o:p>
<TABLE class=MsoNormalTable style="BORDER-RIGHT: medium none; BORDER-TOP: medium none; BORDER-LEFT: medium none; WIDTH: 6.7in; BORDER-BOTTOM: medium none; BORDER-COLLAPSE: collapse; mso-padding-alt: 0in 5.4pt 0in 5.4pt; mso-border-alt: solid windowtext .5pt; mso-border-insideh: .5pt solid windowtext; mso-border-insidev: .5pt solid windowtext" cellSpacing=0 cellPadding=0 width=643 border=1><TBODY><TR style="mso-yfti-irow: 0"><TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: windowtext 1pt solid; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0in; BORDER-LEFT: windowtext 1pt solid; WIDTH: 6.7in; PADDING-TOP: 0in; BORDER-BOTTOM: windowtext 1pt solid; BACKGROUND-COLOR: transparent; mso-border-alt: solid windowtext .5pt" vAlign=top width=643>Name:<o:p></o:p>
<o:p> </o:p>
</TD></TR><TR style="mso-yfti-irow: 1"><TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: #ece9d8; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0in; BORDER-LEFT: windowtext 1pt solid; WIDTH: 6.7in; PADDING-TOP: 0in; BORDER-BOTTOM: windowtext 1pt solid; BACKGROUND-COLOR: transparent; mso-border-top-alt: solid windowtext .5pt; mso-border-alt: solid windowtext .5pt" vAlign=top width=643>Job title:<o:p></o:p>
<o:p> </o:p>
</TD></TR><TR style="mso-yfti-irow: 2; mso-yfti-lastrow: yes"><TD style="BORDER-RIGHT: windowtext 1pt solid; PADDING-RIGHT: 5.4pt; BORDER-TOP: #ece9d8; PADDING-LEFT: 5.4pt; PADDING-BOTTOM: 0in; BORDER-LEFT: windowtext 1pt solid; WIDTH: 6.7in; PADDING-TOP: 0in; BORDER-BOTTOM: windowtext 1pt solid; BACKGROUND-COLOR: transparent; mso-border-top-alt: solid windowtext .5pt; mso-border-alt: solid windowtext .5pt" vAlign=top width=643>Telephone no.:<o:p></o:p>
<o:p> </o:p>
____________________ (Work) ____________________ (Home) ____________________ (Other)<o:p></o:p>
<o:p> </o:p>
</TD></TR></TBODY></TABLE>
<o:p></o:p>
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