Office of Public Health
January 03, 2022
* Loss of taste and smell may persist for weeks or months after recovery and need not delay the end of isolation
**This form is not required by the State of Louisiana to return to work but is intended as a guide to assist employers and employees on when it is safe to return to work. This form is not mandated by the State of Louisiana.
***Employees of congregate settings (nursing homes, prisons) should refer to CDC setting-specific guidance for when to return to work.
****The test must be a negative PCR/molecular test at least five days after exposure to a positive case or suspected illness.
Return-to-Work Self-Certification for COVID-19
*
Persons with COVID-19 symptoms and/or a positive test must:
Stay home for 5 days.
If you have no symptoms or your symptoms are resolving after 5 days, you can return to work.
o If you have a fever, continue to stay home until your fever resolves.
Continue to wear a mask around others for 5 additional days.
o If a mask cannot be worn for 5 additional days, you should isolate for a full 10 days.
Persons suspected of having COVID-19 who have been tested and receive a negative PCR test may discontinue isolation precautions
provided they feel well. Antigen and antibody tests do not rule out suspect COVID-19 cases.
If the employee is sick with non-COVID-19 symptoms, or if the employee has tested negative for COVID-19
****
, the employee’s
symptoms must have improved 24 hours before returning to the worksite. If teleworking or working from home, the employee does
not have to wait the 24 hours before resuming work duties.
If an employee is a close contact (defined as within 6 feet for a cumulative 15 minutes over a 24-hour period) of a COVID-19 case, that
person may return to work if they
***
:
Employee Self-Certification
By signing this document, I verify that I have been symptom-free for the appropriate number of days and that the information
reported above is correct. Therefore, I can be released from isolation or quarantine and may resume work-related activities.
Signature Date
Anyone unable to mask should quarantine for 10 days from their last contact with a case.
Have been boosted, OR
Completed the primary series of Pfizer or Moderna vaccine within the
last 6 months, OR
Completed the primary series of J&J vaccine within the last 2 months
Wear a mask around others for 10 days.
Test of day 5, if possible.
If you develop symptoms, get a test and stay home.
Are unvaccinated, OR
Completed the primary series of Pfizer or Moderna vaccine over 6
months ago and are not boosted, OR
Completed the primary series of J&J over 2 months ago and are not
boosted
Stay home for 5 days. After that continue to wear
a mask around others for 5 additional days.
Test on day 5, possible.
If you develop symptoms, get a test and stay home.
Employees Returning from Isolation
Date of Symptom Onset:
____/____/________
Test Date and Result:
____/____/________
Positive Negative Not Tested
Date of Recovery:
____/____/________
Employees Returning from Quarantine
Date of Last Exposure to COVID+:
____
/____/________
Date to Discontinue Quarantine
____
/____/________
Test Date and Result:
____/____/________
Positive Negative Not Tested
