He/Him She/Her They/Them
M-D-Y
Email
* must provide value
Please provide so EHS can contact you for followup.
Telephone Number
* must provide value
Please provide so EHS can contact you for followup.
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
Who is completing this survey? (If COVID Reaction Line completing on behalf of employee, change response. Initial default response is employee.)
* must provide value
Employee (self)
COVID Reaction Line (on behalf of employee)
Student
Do you work in one of the following areas: Hem/onc, solid organ or bone marrow transplant or neonatal ICU?
* must provide value
Yes
No
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
Choosing Primary Site will send a notification to the site administrators
Are you required to be on site to do your job?
* must provide value
Yes
No
Last Date Onsite
* must provide value
Today M-D-Y
Do you take care of/have contact with patients?
* must provide value
Yes
No
Working in the position different from your current position
Yes
No
Please provide the name of your direct supervisor
* must provide value
Why are you completing this form?
* must provide value
I am experiencing symptoms of COVID-19 and would like an EHS consult
I am reporting high-risk workplace exposure to a COVID-19 patient
I am reporting high-risk community exposure
I am completing this form due to a positive symptom attestation
I was newly diagnosed with COVID-19 in the last 10 days and have not previously reported to EHS
I was asked to complete this form as part of a contact investigation
Bronx VA rotation
I would like an EHS consult AND to request COVID-19 testing
I would like to request COVID-19 testing only
Community
Patient Care
Recent Travel
I received a COVID-19 vaccine
Have you tested positive for COVID-19?
Yes
No
What was the date of your positive COVID test:
* must provide value
Today M-D-Y
Did you receive Monoclonal Antibody Treatment?
Yes
No
Date of Monoclonal Antibody Treatment
Today M-D-Y
Please upload document verifying Monoclonal Antibody Treatment
Was your positive COVID result after recent travel?
* must provide value
Yes
No
Have you previously tested positive for COVID-19?
* must provide value
Yes
No
What was the date of your prior positive PCR?
* must provide value
Today M-D-Y
Are you up to date with your vaccinations?
* must provide value
Yes
No
Which vaccine did you receive?
* must provide value
Pfizer-BioNTech
Moderna
Johnson & Johnson
Date of vaccination
* must provide value
Today M-D-Y
Which dose of the vaccine are you reporting?
* must provide value
First dose
Second dose
Booster # 1
Booster # 2
Today M-D-Y
Are you experiencing any of the following symptoms (select all that apply)?
* must provide value
Fever (>= 100?F) for more than 48 hours
Chills
Rash
Upper Respiratory symptoms (cough, nasal congestion, runny nose or sore throat)
Headache
New onset of loss of sense of taste or smell
Airway-related issues
Tachycardia
Muscle or body aches
Fatigue
Joint pain
No symptoms at this time
If experiencing fever, please provide temperature (F)
* must provide value
Please select the type of community exposure.
* must provide value
A household member was diagnosed with COVID-19 or suspected with having COVID-19 in the last 14 days.
A close contact in the community with a laboratory confirmed cases of COVID-19 (e.g., less than 6 feet for 10 minutes) in the last 14 days.
Bronx VA rotation start date
* must provide value
Today M-D-Y
Bronx VA rotation end
* must provide value
Today M-D-Y
If your symptoms are SEVERE, please call your primary care doctor or go to the ED.
I have reported a positive symptom for COVID-19 illness on my Daily Staff COVID Symptom Attestation.
* must provide value
Yes
No
For COVID-19 nasal swab PCR testing, please indicate if you are currently symptomatic or asymptomatic.
* must provide value
COVID-19 nasal swab - symptomatic
COVID-19 nasal swab - asymptomatic
Which type of COVID-19 testing are you requesting?
* must provide value
COVID-19 nasal swab
COVID-19 antibody testing
If you would like an EHS consult, would you like to speak with someone by phone or telehealth?
* must provide value
Phone
Telehealth
If you had only a high-risk exposure and have exhibited no symptoms, please check here:
High-risk exposure - asymptomatic
Are you experiencing symptoms of COVID-19? - DUPLICATE QUESTION
* must provide value
Yes
No
Are you currently experiencing COVID-19 related symptoms?
* must provide value
Yes
No
If you are reporting symptoms of COVID-19-like illness, what are your symptoms? (select all that apply)
* must provide value
Fever or chills
New onset persistent cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Headache
New loss of taste or smell
Sore throat
New onset runny nose or nasal congestion not related to allergic rhinitis
Nausea or vomiting
Diarrhea
What date did you begin exhibiting symptoms?
* must provide value
Today M-D-Y
Have you recovered from COVID-19 symptoms?
* must provide value
Yes
No
What was the last date you exhibited symptoms?
* must provide value
Today M-D-Y If currently symptomatic, enter today's date.
Today M-D-Y
If you are reporting a high-risk work exposure at an MSHS facility, please select the type of exposure you experienced. (select all that apply)
* must provide value
Prolonged close contact (> 15 minutes and within 6 feet) with a laboratory-confirmed COVID-19 patient, co-worker without a surgical mask.
Not wearing both a surgical mask and appropriate eye protection while in contact with a laboratory-confirmed COVID-19 patient/co-worker/visitor who was not wearing a face covering
Not wearing the recommended Full PPE (N-95 respirator, eye protection, gown, and gloves) while involved in an aerosol generating procedure
None of the above
If you experienced neither of the above high-risk workplace patient exposures, you do not meet criteria of a high-risk work exposure.
Would you like to request an EHS consult to further discuss your exposure?
Yes
No
Are you reporting community exposure?
Yes
No
Please provide additional details about the exposure:
Please indicate the high-level location where the workplace patient exposure occurred:
Ambulatory/Clinic
ED
EMS Worker
ICU
Inpatient
Procedural/Diagnostic Area
For patient contact > 15 minutes without a mask or respirator, please indicate distance from the patient:
1-3 feet
3-6 feet
> 6 ft
Length of Exposure (Hours)
Yes
No
Type of PPE (Choose all the apply)
Gown
Gloves
Mask n95
Mask Papr
Half Face Mask with Filter
Surgical Mask
Face Shield
Goggles
Safety Glasses
Are you fit tested for an N-95 respirator?
Yes
No
Are you interested in enrolling in research for COVID-19?
Yes
No
Are you currently out from work?
* must provide value
Yes
No
If yes, what was your last day of work?
* must provide value
Today M-D-Y
Have you seen an EHS provider via telehealth?
Yes
No
If yes, when was your visit?
Today M-D-Y
Have you discussed a potential return-to-work date with an EHS provider?
Yes
No
Do you have any underlying conditions?
Yes
No
Please select your underlying condition(s)
Chronic Lung disease/Asthma
Diabetes
Heart disease
Obesity
Autoimmune disease
Other
Have you been tested for COVID-19 antibodies?
Yes
No
Have you filled this form out before?
Yes
No
If Yes, please describe what changed from the last time you filled out this form.
Upload Document: If you have any documentation you would like to provide to EHS, you can upload it here.
Upload Document: If you have outside documentation of COVID-19 PCR testing, you may upload it here.
Upload Document: If you have documentation of outside COVID-19 antibody testing, you may upload it here.
Survey Date (Hidden - for back-end use)
Today M-D-Y
