COVID-19 Screening and Reporting Tool - Vendor
Vendor Information
First Name
Last Name
Email
Date of Birth
Phone Number
Reason for visiting campus
Username
Visit Information
Primary Role
Job Title
Contact person at OU
Contact person phone number
Department/College
Building(s) to be visited
Campus
OKC
Tulsa
Lawton
Expected date of arrival to campus/workplace
Symptom Information
Have you experienced any symptoms within the last 14 days?
Yes
No
Experiencing chills?
Yes
No
Experiencing congestion or runny nose?
Yes
No
Experiencing cough?
Yes
No
Experiencing diarrhea?
Yes
No
Experiencing fever?
Yes
No
Experiencing headache?
Yes
No
Experiencing loss of taste or smell?
Yes
No
Experiencing muscle pain?
Yes
No
Experiencing nausea or vomiting?
Yes
No
Experiencing shortness of breath?
Yes
No
Experiencing sore throat?
Yes
No
Experiencing other symptoms?
Date of Onset of First Symptom
Have all of your symptoms resolved?
Yes
No
Date symptoms resolved
Additional comments regarding symptoms
Exposure Information
Have you been within 6 feet for 15 minutes or longer with someone with Confirmed (+) COVID-19 within the last 14 days?
Yes
No
Have you been within 6 feet for 15 minutes or longer with someone awaiting COVID-19 test results within the last 14 days?
Yes
No
Have you been present for any Aerosol Generating Procedures (AGPs) within the last 14 days?
Yes
No
Do you share a household with someone who has been experiencing symptoms of concern within the last 14 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 tested positive (or date of test if results still pending)
Additional comments regarding exposure
Testing Information
Have you been tested for COVID-19 within the last 14 days?
Yes
No
Test result
Results Pending
Negative
Positive
Test date
Test type
PCR
Rapid PCR
Rapid Antigen
Saliva test
Unknown
Test location
Additional comments regarding tests
Acknowledgement
The information submitted on this form is complete and accurate to the best of my knowledge.
I acknowledge that this screening tool is being used for clearance to visit campus for the specified reasons and dates stated within this form, 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 understand this information is being collected for the purpose of infection prevention and public/employee safety.
I Agree
Username
Ppe
Procedures