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 Oklahoma within the last 14 days?

Event Attendance

Have you attended an event/entertainment venue/gathering or group of greater than 10 people in the last 14 days? The people in your household do not count towards the 10 people.

Symptom Information

Have you experienced any symptoms within the last 14 days?

Exposure Information

Have you had direct contact with Confirmed (+) COVID-19 within the last 14 days?
Have you had direct contact to someone awaiting COVID-19 test results within the last 14 days?
Have you had direct contact with a person experiencing symptoms of concern for COVID-19 within the last 14 days?
Do you share a household with anyone who has had symptoms of concern for COVID-19 within the last 14 days?
Do you share a household with anyone who has been instructed to Self-Isolate within the last 14 days?
Do you share a household with anyone who has been diagnosed with COVID-19 within the last 30 days?

Testing Information

Have you tested POSITIVE for COVID-19 within the last 20 days?

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.