COVID-19 Screening and Reporting Tool - New Employee

Employee Information

Employment Information

Are you healthcare personnel?
Healthcare personnel are defined as persons in a healthcare setting with the potential for direct or indirect exposure to patients or infectious materials

Symptom Information

Have you experienced any symptoms within the last 10 days?

Exposure Information

Have you had close contact with someone with Confirmed (+) COVID-19 within the last 10 days?
Have you been present for any Aerosol Generating Procedures (AGPs) within the last 10 days?
Is this person a member of your household?

Testing Information

Have you been tested for COVID-19 within the last 10 days?
Have you tested positive for COVID-19 within the last 90 days?

Vaccination Information

Have you received a COVID-19 vaccination?


The information submitted on this form is complete and accurate to the best of my knowledge.

I acknowledge that this form is for a general return to work decision, based on information I provided. It is not intended for use regarding personal medical evaluation, advice, decisions, and/or treatment. Seek care from your primary care provider or emergency services, as appropriate, for any personal medical needs.

I submit this information for use related to return to work and administrative decisions related to my workplace. I understand this information is being collected for the purpose of infection prevention and public/employee safety.