COVID-19 Screening and Reporting Tool - New Employee
Date of Birth
Employee ID #
Contact person at OU
Contact person phone number
Healthcare worker with direct patient care responsibilities?
Expected date of arrival to campus/workplace
Most recent date you were on campus or at workplace
Have you traveled or resided outside of Oklahoma within the last 14 days?
Have you spent time on a cruise ship within the last 14 days?
Additional comments regarding travel
Have you attended an event/entertainment venue/gathering or group of greater than 10 people in the last 14 days?
Additional comments regarding event/entertainment venue/gathering or group
Have you experienced any symptoms within the last 14 days?
Experiencing congestion or runny nose?
Experiencing loss of taste or smell?
Experiencing muscle pain?
Experiencing nausea or vomiting?
Experiencing shortness of breath?
Experiencing sore throat?
Experiencing other symptoms?
Date of Onset of First Symptom
Have all of your symptoms resolved?
Date symptoms resolved
Additional comments regarding symptoms
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?
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?
Date of Exposure
Non-clinical office setting
Other healthcare setting
Other non-healthcare setting
Specific location of exposure
Were you wearing a mask at time of exposure?
Employee PPE worn at time of exposure
Eye protection (face shield)
Eye protection (goggles or safety glasses)
No PPE worn
Select any Aerosol Generating Procedures (AGPs) involved in the exposure
Bag mask ventilation
Endotracheal intubation and extubation
GI endoscopy procedure
High flow oxygen delivery
Nasopharyngeal washing, aspirate, and scoping
Nebulized medication administration
Open suctioning of airways
Positive pressure ventilation (BiPAP & CPAP)
Suctioning of tracheostomy
Was source wearing a mask?
Date exposure source tested positive (or date of test if results still pending)
Additional comments regarding exposure
Have you been tested for COVID-19 within the last 14 days?
Additional comments regarding tests
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.