The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit North American phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

NgMBWYAFZbHipEresIWumS8F745Pxw

Emerging Viral Disease Exposure

This survey should be used to register symptoms or a high risk exposure to an emerging viral disease.

A daily symptom monitoring tool will be sent to you via email once your initial assessment is completed by Employee Health Service (EHS).

Please do not report Covid-19 like symptoms or a recent positive Covid-19 test. This information is not being collected via Redcap.

First Name

Last Name

Preferred Pronoun

Date of Birth

M-D-Y

* must provide value

Telephone Number

* must provide value

Are you a health care worker taking care of patients?

* must provide value

Yes

reset

Life Number
(if you do not have a life number, please put NA. If you do not know your life number, please put Unknown.)

* must provide value

Job Position

Primary Site

MSB - Mount Sinai Brooklyn

MSC - Mount Sinai Corporate

MSH - Mount Sinai Hospital

MSN - Mount Sinai Nassau

MSQ - Mount Sinai Queens

MSW - Mount Sinai West

MSM - Mount Sinai Morningside

NYEE - New York Eye & Ear Infirmary of Mount Sinai

Offsite

reset

Please provide the name of your direct supervisor

* must provide value

Symptomatic employees will be removed from work and need to self-isolate

Why are you completing this form?

Please do not report Covid-19 like symptoms or a recent positive Covid-19 test. This information is not being collected via Redcap.

* must provide value

I am reporting workplace exposure

I am reporting community exposure

I was newly diagnosed and have not previously reported to EHS

I have a presumptive diagnosis of viral infections (Monkeypox, Ebola, etc.)

reset

What were you exposed to?

Monkeypox

Viral hemorrhagic fever (e.g. Ebola, Lassa fever)

Other

reset

If other, please enter here:

Who is completing this survey?

* must provide value

Employee (self)

reset

Please select the type of community exposure.

* must provide value

A household member was diagnosed.

A close contact in the community with a laboratory confirmed case (e.g., less than 6 feet for 3 hours or more without a surgical mask).

reset

If your symptoms are SEVERE, please call your primary care doctor or go to the ED.

Are you currently experiencing symptoms?

* must provide value

Yes

reset

If you are reporting symptoms, what are your symptoms? (select all that apply)

* must provide value

Fever or chills

Rash

Swollen lymph nodes

Unexplained hemorrhaging, bleeding or bruising

Muscle and joint pain

Weakness and fatigue

Sore throat

Loss of appetite

GI symptoms (abdominal pain, diarrhea, and vomiting)

Cough

Did you receive a positive test?

* must provide value

Yes

reset

Positive Test Date

M-D-Y

What did you test positive for?

* must provide value

If experiencing fever, please provide temperature (?F)

* must provide value

What date did you begin exhibiting symptoms?

* must provide value

M-D-Y

Have you recovered from symptoms?

* must provide value

Yes

reset

What was the last date you exhibited symptoms?

* must provide value

M-D-Y

Date of Exposure

M-D-Y

Length of Exposure (Hours)

If you were exposed to a patient, please provide patient MRN (if available):

* must provide value

Were you wearing PPE?

* must provide value

Yes

reset

Type of PPE (Choose all that apply)

* must provide value

Gown

Gloves

Mask n95

Mask Papr

Half Face Mask with Filter

Surgical Mask

Face Shield

Goggles

Safety Glasses

Did you have any contact with the patient?

* must provide value

Yes

reset

Does the contact involves -

Skin to Skin contact, bathing, changed linens, cleaned commode, assisted patient from bed to chair, help with dressing etc.

Yes

reset

Were you within 6 ft of a patient during any of the procedures without wearing an N95 and eye protection? (check all that apply))

* must provide value

Procedure that may create aerosols from oral secretions

Intubation

CPR

Contact with skin lesions

Resuspension of dried exudates

Unroofing or Incision & Drainage of Lesions

Surgery

None of the above

Are you currently out from work?

* must provide value

Yes

reset

If yes, what was your last day of work?

* must provide value

M-D-Y

Do you have any underlying conditions?

Yes

reset

Please select your underlying condition(s)
[select all that apply]

Chronic Lung disease/Asthma

Diabetes

Heart disease

Obesity

Autoimmune disease

Immunosuppressed

Other

Notes

Expand

Have you filled this form out before?

Yes

reset

If Yes, please describe what changed from the last time you filled out this form.

Expand

Upload Document: If you have any documentation you would like to provide to EHS, you can upload it here.

Upload file

Upload pictures: If you have any pictures you would like to provide to EHS, you can upload it here.

Upload file

Upload pictures: If you have any pictures you would like to provide to EHS, you can upload it here.

Upload file

Upload pictures: If you have any pictures you would like to provide to EHS, you can upload it here.

Upload file

Upload pictures: If you have any pictures you would like to provide to EHS, you can upload it here.

Upload file

Survey Date (Hidden - for back-end use)

M-D-Y

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.