Reporting Period:7/6/2020 - 9/16/2020
If you have an employee that has tested positive for COVID-19 on or after July 6, 2020 to September 16, 2020, you are
required to promptly notify us with the information required in this form.
You are required to report this information to us no later than 30 business days after law effective date.
You must complete this form whether or not the illness is work-related and whether or not your employee
has filed a claim.
If your employee contends that the illness is work-related, you must report the claim in addition to
completing this form.
If the testing date is on or after September 17, 2020, then you cannot use this reporting form. You must use SB 1159 COVID-19 Reporting Form 2 to report information about any employees who tested positive for COVID-19 on or after September 17, 2020.
If you have more than one employee who has tested positive for COVID-19, you must complete a separate
form for each employee.
For each employee you report, please keep internal records identifying the employee by name for future