Related Materials: AB 685: Q&A for Employers | AB 685: Employer Guidance on Definitions | More Employees & Workplaces Guidance | All Guidance
Respiratory OB form:
Workplace Information section:
Occupation of affected workers, and number of workers in each occupation.
Local health departments can contact the CDPH Occupational Health Branch at any time with questions or requests for assistance regarding workplace COVID-19 outbreaks.
Please note: This template is intended to allow for collection of data that employers are required to report to local health departments under AB 685. Local health departments may also choose to collect additional information from employers regarding workplace outbreaks.
Date of report: ____________
Name of reporter: _______________________________________
Business or facility name: _______________________________
Business address: _______________________________________
Type of business: _______________________________________
This is the industry of the business, such as elementary school, clothing manufacturing, restaurant, or grocery store.
[Suggest collecting this information as a free text field]
NAICS code: ________
The North American Industry Classification System (NAICS) code is a standard 6-digit code used to classify a workplace by industry. To find your business's NAICS code, first click your sector number, then search for the specific code for your industry.
Total number of workers at the worksite: ________
Please include all workers, including temporary or contract workers.
Number of workers with COVID-19: ________
This includes any workers known to have tested positive by either rapid antigen test or PCR test.
Collect for each worker with COVID-19. Local health departments may also wish to collect additional information about workers with COVID-19 to assist with case investigation and contact tracing efforts, such as worker date of birth, contact information, date of positive test, date of symptom onset, and date last present at the worksite.
Occupation is the kind of work someone does (e.g. registered nurse, janitor, cashier, auto mechanic, etc). [Suggest collecting this information as a free text field]
Originally Published on December 10, 2020