COVID-19 Screening and Reporting Tool - New Employee


Employee Information

Employment Information

Do you work in a healthcare facility?
Do you live in University Housing?

Travel History

Have you traveled to the United States from another country (does not apply to US territories) within the past 14 days?
Have you been on a river or ocean cruise, domestic or international, within the last 14 days?

Symptom Information

Have you experienced any symptoms within the last 14 days?

Exposure Information

Have you been within 6 feet for 15 minutes or longer with someone with Confirmed (+) COVID-19 within the last 14 days?
Have you been within 6 feet for 15 minutes or longer with someone awaiting COVID-19 test results within the last 14 days?
Is this person a member of your household?

Testing Information

Have you tested POSITIVE for COVID-19 within the last 14 days?

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.