COVID-19 Employee & Medical Staff Screening Form

Your Name (required)

Employed Facility (required)

Best phone number to reach you (required)

Best Email to reach you (required)

Direct supervisor's Name (required)

I am screening for (must choose one)
Contact with COVID-19Symptoms of influenza-like illness
Date of Contact- Contact of COVID-19 or Date of Symptoms for Flu (required)

Source of Contact (required)

Location of Contact (required)

Length of Contact (required)

Prolonged close contact? (Within 6 ft for at least 10 consecutive minutes)
YesNoNot Applicable
The following questions are to be answered if your COVID-19 exposure was in the hospital.
What is your relation to the person with COVID-19?
PatientCo-workerNot Applicable
Were you present for aerosol- or cough-generating procedure (cardio-pulmonary resuscitation, intubation, extubation, non-invasive positive pressure ventilation, bronchoscopy, nebulizer therapy, sputum induction, nasogastric tube placement, open suctioning of airway)?
YesNoNot Applicable
Did you have direct contact with the patient’s body fluids/secretions such as being coughed on or cleaning the patient after toileting?
YesNoNot Applicable
Was the patient/co-worker wearing a face mask?
YesNoNot Applicable
Were you wearing a face mask?
Surgical MaskN-95PAPRNo MaskNot Applicable
Were you wearing eye protection?
YesNoNot Applicable
Were you wearing a gown?
YesNoNot Applicable
Were you wearing gloves?
YesNoNot Applicable
Current Symptoms of an influenza-like illness. If you chose symptoms of influenza-like illness, please check the following symptoms you are experiencing.
Fever Higher than 100ChillsCoughSore ThroatShortness of BreathAches & PainsDiarrheaVomiting
Have you sought care from your personal physician?
YesNo
Do you have any chronic medical conditions (lung disease, heart disease, diabetes, current chemotherapy) which would put you at risk?
YesNo