Gallagher Bassett COVID-19 Tracker

Please use this form to report information about non-work-related COVID infections as required by California SB1159.

Reporting Contact

First Name

Last Name

Company Name

Client ID (Gallagher Bassett Client #)

COVID-Positive Information

Employee ID

(for person who tested positive)

Date Positive Test Was Taken

(note: this is not the date of the positive diagnosis, but the date the test was administered)

Exposed Site Information

Primary Site Information
(provide information for the primary site the infected employee reports to or was working in 14 days prior to the date the positive test was taken)

Primary Site Location Street Address

Primary Site Location City

Primary Site Location State

Primary Site Location Zip

Primary Site Location GB Pyramid Unit #

Maximum number of employees at this physical location in the 45 days prior to the test date

Secondary Site Information 1
(provide information for other sites this individual worked in 14 days prior to the date the positive test was taken)

Secondary Site Location #1 Street Address

Secondary Site Location #1 City

Secondary Site Location #1 State

Secondary Site Location #1 Zip

Secondary Site Location #1 GB Pyramid Unit #

#1: Maximum number of employees at this physical location in the 45 days prior to the test date

Secondary Site Information 2
(provide information for other sites this individual worked in 14 days prior to the date the positive test was taken)

Secondary Site Location #2 Street Address

Secondary Site Location #2 City

Secondary Site Location #2 State

Secondary Site Location #2 Zip

Secondary Site Location #2 GB Pyramid Unit #

#2: Maximum number of employees at this physical location in the 45 days prior to the test date

Secondary Site Information 3
(provide information for other sites this individual worked in 14 days prior to the date the positive test was taken)

Secondary Site Location #3 Street Address

Secondary Site Location #3 City

Secondary Site Location #3 State

Secondary Site Location #3 Zip

Secondary Site Location #3 GB Pyramid Unit #

#3: Maximum number of employees at this physical location in the 45 days prior to the test date

Required Field