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Please review the following scenarios to confirm if any of the following apply to you before proceeding:

1. Do you have any of the following symptoms?

Fever (>37.8 degrees C / 100 degrees F) or chills
Cough
Shortness of breath/difficulty breathing
Diarrhea - greater than three loose stools in a 24 hour period
Vomiting
Sore throat
Loss of smell or taste, or a change in taste
Body/muscles aches or fatigue
Headache
Congestion/runny nose
Nausea

2. Have you received a positive COVID-19 test result?

**If you have answered YES to either of these scenarios, proceed with filling out the online intake form. You will receive an e-mail guidance within 24-72 hours of your submission.

If you experienced a higher-risk work or community exposure, refer to the Ability to Work Guidelines for guidance. For higher-risk work exposures, please inform your leader and proceed with filling out an Exposure Report Form.

Todays date

* First name

* Last name

* Employee A or D #

* Preferred e-mail that can be accessed outside of a work computer (personal e-mail)

* Preferred Phone Number

* OK to leave detailed message?

* Name of Leader

* Work site and job title

* What is your usual shift/start time?

* Are you severely immunocompromised?

See page 6 of the Ability to Work Guidelines for "immunocompromised" definition

What is the last shift that you worked?

When was the first day that you missed work?

* Are you experiencing COVID-19 related symptoms?

* If yes, when did the symptoms start?

If yes, did your symptoms start on-shift?

* Did you have a known COVID-19 exposure at home or outside of work within 5 days of symptom onset? (examples: friends, family members, events)

If yes, what type of precautions was the patient in?

If yes, what length of time were you with the patient?

If yes, what type of PPE were you wearing?

* Did you take care of a known or suspected COVID positive patient and have a breach in your PPE within 5 days of symptom onset?

* Did you have a known exposure to a COVID positive co-worker within 5 days of symptom onset?

* Have you taken a COVID-19 test related to this encounter?

* If yes, when did the test occur?

* If yes, what was the result?

* If yes, what was the type of test?

* If yes, when did the test occur?

* If yes, what was the result?

* If yes, what was the type of test?