Potential Coronavirus Exposure Screening Form
1. Demographics:
Employee Name _____________________________________________________________
Employee ID _________________________
Telephone_______________________
Email_______________________________
Work Location____________________
Agreement/Non-agreement
IF AGREEMENT HAS OHN OPENED A SERVICE YES
NO If Yes, Date opened__________
2. Basic Information:
a. How was the employee potentially exposed? _____ Travel _____ Known Case
b. Is employee asking for accommodation for his/her own health condition?
c. Details: Describe where, how, what, why including dates
d. Any symptoms? ______Yes
_____No
i. If yes, what symptoms?
Symptom Present?
Fever >100.4F (38C)c
Yes
No
Unk
Subjective fever (felt feverish)
Yes
No
Unk
Chills
Yes
No
Unk
Muscle aches (myalgia)
Yes
No
Unk
Runny nose (rhinorrhea)
Yes
No
Unk
Sore throat
Yes
No
Unk
Cough (new onset or worsening of chronic cough)
Yes
No
Unk
Shortness of breath (dyspnea)
Yes
No
Unk
Nausea or vomiting
Yes
No
Unk
Headache
Yes
No
Unk
Abdominal pain
Yes
No
Unk
Diarrhea (≥3 loose/looser than normal stools/24hr
Yes
No
Unk
period)
Other, specify:_____________________________________________
3. Disposition:
a.
b.
c.
d.
Details
Check ones that apply; HMS guidance to employee based upon above:
____If symptomatic with travel or known contact potential exposure, then remain at
home and contact PCP and local health department
_____If asymptomatic and history of travel to high risk areas (China, S Korea, Japan,
Italy, Iran, etc), US hot spots, or potentially known contact, then stay home and contact
local health department
_____If asymptomatic and history of international travel and/or have had any cruise
ship travel then, stay home and call local health department for guidance
____Anticipated RTW date:____________
4. HMS Close Out
a. Follow-up Notes/Calls
b. Final Disposition including actual RTW date: