COVID-19 Reporting

Concern & Vaccination Verification

Thank you for contacting the GEA COVID-19 Response Team with a concern related to COVID-19 and/or to report COVID-19 vaccination verification.

If you are reporting a concern related to exposure to COVID-19, a healthcare professional will be in contact with you.

If you are providing information about having received the COVID-19 vaccine, please select “Have received the COVID-19 vaccination” from the second box below.

ATTENTION FACTORY SERVICE TECHNICIANS You should only complete this form to report COVID-19 vaccination verification. If you have a concern related to exposure to COVID-19 please contact your Manager or Human Resources Manager to ensure correct processing.

Are you contacting us to report in relation to:

Please go to this link to report your Ombuds concern/question. Raising a concern can be done anonymously and your information is kept confidential.

Describe your relationship to the person whose exposure you are reporting

Please explain why you are contacting us:

Describe your concern:

Reporting Person's Details

First Name:

Last Name:

SSO

Email:

Phone Number:

Affected Person's Information

First Name

Last Name

SSO

Phone Number

GEA Manager / Sponsor Name

GEA Manager / Sponsor Email

Location of affected person

Facility

State or Country

Location Name

Have you, or the person on whose behalf you are reporting, been advised to self-quarantine?

YesNo

Please provide every detail you recall about the circumstances for which you (or the person you are reporting for) were asked to self-quarantine

What date were you advised to self-quarantine?

What date do you expect to stop self-quarantine?

Have you, or the person on whose behalf you are reporting, received a coronavirus test (i.e., a swab of your nose or other similar test)?

YesNoI don't know

What did your health care provider tell you about why a coronavirus test is not needed?

What was the outcome of your test?

I have coronavirusI don't have coronavirusI don't know

Please describe any testing your physician has completed

Is the person for whom you are reporting currently off of GEA property?

YesNo

NOTE: If you received a one-dose vaccine, please put the date in both fields.

1st Dose COVID-19 Date

2nd Dose COVID-19 Date

In addition to providing your COVID-19 vaccination dates, please upload an image of the front of your vaccination card for verification

Notice at Collection:

GEA uses this form to collect data related to exposure to COVID-19, temperature screening failures, diagnoses of COVID-19, and vaccination status. Data collected includes identifiers such as your name, email address, phone number, SSO, geographic location, and vaccinations you have received.

We collect this data to enable GEA management to notify our medical team that you may need support in managing COVID-19 concerns, to determine how COVID-19-related safeguards may apply to you, to make decisions related to the operation of GEA’s business, and for other COVID-19-related purposes.

To view our Employee Data Protection Policy, visit click here.

Please click submit below.