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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).

If you are experiencing symptoms of Covid-19 like illness or have a recent positive PCR, please register your symptoms by clicking this link: https://is.gd/employee_covid_registry

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

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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

MSBI - Mount Sinai Beth Israel

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

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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?

Do Not complete this survey if you are reporting COVID-19 like symptoms. For�Employees with COVID-19 related symptoms or need COVID-19 testing should complete the survey at the following link:�https://is.gd/employee_covid_registry

�

* 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.)

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What were you exposed to?

Monkeypox

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

Other

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If other, please enter here:

Who is completing this survey?

* must provide value

Employee (self)

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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).

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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

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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

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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

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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

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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

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Does the contact involves -

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

Yes

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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

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If yes, what was your last day of work?

* must provide value

M-D-Y

Do you have any underlying conditions?

Yes

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

Chronic Lung disease/Asthma

Diabetes

Heart disease

Obesity

Autoimmune disease

Immunosuppressed

Other

Notes

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Have you filled this form out before?

Yes

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

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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

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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.