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Required format:

jhgHXxUFvaCkB2LxFc4JvIu97dHLDorVsVRJEvu7Mfpx3vDbeUQ3fCqAVHxfy6K5xvhYoPC2WAuPhfScVYCzXQEtmMbifn4e4pyyBEinSRLNcgvsqZPyiWQmath6

EHS Registry for Reporting COVID-19-like Illness or Positive COVID-19 Test

This survey should be used to register symptoms of COVID-19-like illness or a recent positive PCR. If you have already submitted a survey in the past 48 hours, please do not submit an additional survey.

Please do not use this form to submit your vaccination status. Vaccination status (including booster) should be reported here.

For more information and resources, please visit:

https://www.mountsinai.org/about/covid19/staff-resources/employee-health

First Name

Last Name

Preferred Pronoun

Date of Birth

M-D-Y

* must provide value

Telephone Number

* must provide value

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

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Do you work in one of the following areas: Hem/onc, solid organ or bone marrow transplant or neonatal ICU?

* must provide value

Yes

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Additional testing for heme/onc, solid organ or bone marrow transplant, neonatal ICU departments: Employees with a negative COVID-19 test and with continued symptoms are advised to also test for Flu and RSV.

Job Position

Department

Primary Site

MSB - Mount Sinai Brooklyn

MSC - Mount Sinai Corporate

MSH - Mount Sinai Hospital

MSSN - Mount Sinai South Nassau

MSQ - Mount Sinai Queens

MSW - Mount Sinai West

MSM - Mount Sinai Morningside

NYEE - New York Eye & Ear Infirmary of Mount Sinai

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Are you required to be on site to do your job?

* must provide value

Yes

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Last Date Onsite

* must provide value

M-D-Y

Do you take care of/have contact with patients?

* must provide value

Yes

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Please provide the name of your direct supervisor

* must provide value

For policy details: COVID-19 Monitoring

Why are you completing this form?

* must provide value

I am experiencing symptoms of COVID-19

I was newly diagnosed with COVID-19 in the last 10 days and have not previously reported to EHS

I was newly diagnosed with COVID-19 and isolated for at least 5 days by EHS (in the last 10 days) and need a reassessment

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Have you been tested for COVID-19 (home test or PCR test)?

* must provide value

Yes - PCR test at a lab within Mount Sinai Health System

Yes - PCR/Antigen test at an external lab

Yes - home test

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Do you have your test results? (If test result is pending, please answer No)

* must provide value

Yes

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Have you tested positive for COVID-19?

* must provide value

Yes

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What was the date of your positive COVID test:

* must provide value

M-D-Y

Upload Document: If you have outside documentation of COVID-19 PCR testing, you may upload it here.

Upload file

Are you currently experiencing COVID-19 related symptoms?

* must provide value

Yes

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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

M-D-Y

Have you previously tested positive for COVID-19?

* must provide value

Yes

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What was the date of your prior positive PCR?

* must provide value

M-D-Y

Notes

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Are you currently receiving chemotherapy treatment for cancer?

Yes

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Have you received bone marrow or organ transplant?

Yes

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Are you taking long term steroid medications?

Yes

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List the steroid medications you are taking:

Please specify your underlying medical condition:

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

Other

Please specify your other underlying condition.

Are you currently taking medications for your underlying conditions?

Yes

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Please list the medications you are currently taking

OSHA Questions (if positive covid-19 test):

Did you have contact with a known or suspected covid patient in the 14 days prior to symptom onset?

* must provide value

Yes

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Did you work in an area with close and frequent contact with patients under investigation (PUI) patients in the 14 days prior to symptoms onset?

* must provide value

Yes

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Did you have an exposure to a known or suspected covid positive individual at home or in the community or during travel in the last 14 days?

* must provide value

Yes

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Did you receive Monoclonal Antibody Treatment?

Yes

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Did you receive Paxlovid?

Yes

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Date of Monoclonal Antibody Treatment

M-D-Y

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

Upload file

Please upload document verifying Monoclonal Antibody Treatment

Upload file

Upload Document: If you have documentation of outside COVID-19 antibody testing, you may upload it here.

Upload file

Helpful Links:

Mount Sinai Staff COVID-19 Resources

Mount Sinai Questions Regarding Your Health

Mount Sinai Well-Being During COVID-19

Helpful download:

Attachment:Patients Guide.pdf

Helpful download:

Attachment:MSHS-COVID-19-PPE-Practices.pdf

Survey Date (Hidden - for back-end use)

M-D-Y

Are you interested in clinical trials?

Yes

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If select yes, please call 212-824-7714 or email ctrctrialsinfo@mountsinai.org for additional information about clinical trails

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.