COVID-19 Screening and Reporting Tool - New Employee


Employee Information

Employment Information

Healthcare worker with direct patient care responsibilities?

Travel History

Have you traveled or resided outside of the United States within the last 14 days?
Have you spent time on a cruise ship within the last 14 days?

Symptom Information

Have you experienced any symptoms within the last 14 days?

Exposure Information

Have you had close contact with someone with Confirmed (+) COVID-19 within the last 14 days?
Have you had close contact with someone awaiting COVID-19 test results within the last 14 days?
Have you been present for any Aerosol Generating Procedures (AGPs) within the last 14 days?
Do you share a household with someone who has been experiencing symptoms of concern within the last 14 days?
Is this person a member of your household?

Testing Information

Have you been tested for COVID-19 within the last 14 days?
Have you EVER tested positive for COVID-19?

Vaccination Information

Have you received a COVID-19 vaccination?

Acknowledgement


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.