COVID-19 Screening and Reporting Tool - New Employee
Employee Information
First Name
Last Name
Email
Date of Birth
Phone Number
Employee ID #
Last 4 digits of Social Security Number
Username
Primary Role
Direct supervisor email
Employers
Ppe
Procedures
Employment Information
Employer
HSC-OKC
OU-Tulsa
OU Health
Contact person at OU
Contact person phone number
Job Title
Job Description
Department Name
Department Code
Direct Supervisor
Campus
OKC
Tulsa
Lawton
Are you healthcare personnel?
Yes
No
Healthcare personnel are defined as persons in a healthcare setting with the potential for direct or indirect exposure to patients or infectious materials
Expected date of arrival to campus/workplace
Most recent date you were on campus or at workplace
Symptom Information
Have you experienced any symptoms within the last 10 days?
Yes
No
Experiencing chills?
Yes
No
Experiencing congestion or runny nose?
Yes
No
Experiencing cough?
Yes
No
Experiencing fever?
Yes
No
Experiencing headache?
Yes
No
Experiencing loss of taste or smell?
Yes
No
Experiencing muscle pain?
Yes
No
Experiencing shortness of breath?
Yes
No
Experiencing sore throat?
Yes
No
Date of Onset of First Symptom
Have all of your symptoms resolved?
Yes
No
Date symptoms resolved
Have you had close contact while unmasked with anyone on campus since two days before your symptoms onset?
Yes
No
Additional comments regarding symptoms
Exposure Information
Have you had close contact with someone with Confirmed (+) COVID-19 within the last 10 days?
Yes
No
Have you been present for any Aerosol Generating Procedures (AGPs) within the last 10 days?
Yes
No
Is this person a member of your household?
Yes
No
Date of Exposure
Exposure Setting
Community
Private Residence
Emergency department
ICU
Inpatient
Outpatient clinic
Non-clinical office setting
Other healthcare setting
Other non-healthcare setting
Specific location of exposure
Were you wearing a mask at time of exposure?
Yes
No
Employee PPE worn at time of exposure
Eye protection (face shield)
Eye protection (goggles or safety glasses)
Gloves
Gown
N95 respirator
Surgical mask
No PPE worn
Other
Specify
Select any Aerosol Generating Procedures (AGPs) involved in the exposure
Bag mask ventilation
Bronchoscopy
Bronchoalveolar lavage
Cardiopulmonary resuscitation
Dental procedure
Endotracheal intubation and extubation
GI endoscopy procedure
High flow oxygen delivery
Laryngoscopy
Mechanical ventilation
Nasopharyngeal washing, aspirate, and scoping
Nebulized medication administration
Open suctioning of airways
Positive pressure ventilation (BiPAP & CPAP)
Sputum induction
Suctioning of tracheostomy
Other
Specify
Was source wearing a mask?
Yes
No
Date exposure source developed symptoms
Date exposure source tested positive (or date of test if results still pending)
Please provide a detailed explanation of your exposure including specific dates, symptoms, and test results of those involved
Testing Information
Have you been tested for COVID-19 within the last 10 days?
Yes
No
Have you tested positive for COVID-19 within the last 90 days?
Yes
No
Date of most recent positive COVID-19 test
Type of most recent positive COVID-19 test
PCR
Rapid PCR
Rapid Antigen
Saliva test
Unknown
Test result
Results Pending
Negative
Positive
Test date
Test type
PCR
Rapid PCR
Rapid Antigen
Saliva test
Unknown
Test location
Have you had close contact while unmasked with anyone on campus since two days before your positive test?
Yes
No
Additional comments regarding tests
Vaccination Information
Have you received a COVID-19 vaccination?
Yes
No
Which COVID-19 vaccination did you receive?
Pfizer
Moderna
Novavax
Janssen (J&J)
Other
Please specify:
COVID-19 vaccination
1st
dose date:
COVID-19 vaccination
2nd
dose date:
Have you received a COVID-19 booster?
Yes
No
Which COVID-19 booster did you receive?
Moderna Omicron
Moderna
Pfizer Omicron
Pfizer
Other
Please specify:
Date of COVID-19 booster?
I have had an additional COVID-19 booster
Remove last COVID-19 booster
Additional comments regarding vaccinations
Which COVID-19 booster did you receive?
Moderna Omicron
Moderna
Pfizer Omicron
Pfizer
Other
Please specify:
Date of COVID-19 booster?
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.
I Agree