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

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.