Staff Illness/Exposure Reporting Tool (SIRT)

Use this form to report:

New High Risk COVID-19 exposure (at home, in the community, or at work)

New positive COVID-19 test result

If you are reporting symptoms, please take a Covid test before completing the form.

Name (First and Last)*

OMC Email Contact*

Please enter your OMC email address

Phone Contact*

List the best phone number to contact you (not work number)

Alternative Phone Number

If you have a alternate phone number for whatever reasons, please provide. Skip question if not applicable.

Manager/Supervisor*

What is your manager/supervisor's first and last name?

Department*

Select your department

Select or enter value

Department: Other

Please write your department if not listed in dropdown above

Reporting Category*

Which of the following are you reporting? (Select ALL that apply):

Exposure - you want to report a new potential COVID-19 exposure from a patient, co-worker, family member, friend, etc.
Symptoms - you have developed new symptoms consistent with COVID-19 (see symptom list below)
Home Positive Test - you would like to report a new home positive test you have taken that has not already been reported to OMC (e.g. home antigen test, or PCR done at another facility)

Exposure

Symptoms

Home Positive Test

Important: For Symptomatic Individuals

If you are symptomatic ONLY (no exposure) and your COVID test result is negative, we do NOT need you to finish completing this form.

Please reach out to your manager to coordinate calling out sick, if needed.
Wear a mask at work and social distance for as long as symptoms persist.

If you are symptomatic and recording an exposure, but your COVID result is negative, please complete the form.

Symptom Start Date*

What date did your symptoms first start?

Have you taken a COVID-19 Test?*

If you are experiencing new symptoms, please take a covid test as soon as possible. If you need a covid test, reach out to your department management team.

Yes

Testing Requirement

Please finish completing this form when you have your COVID test result.

COVID Test Result*

Positive

Negative

Home Test Positive Date*

What was the date of your home positive test?

NOTE - we may ask you to help us confirm your home positive with an image of your test or some other method that is mutually convenient.

Prior COVID-19 Infection? *

Have you ever previously had a COVID-19 Infection?

(Not your current illness)

Yes

Exposure Details

Exposure Risk Factors*

Please check each exposure risk factor met while in contact with a confirmed COVID-19 person.

You were unmasked (or not wearing an N95 during an AGP with a known COVID+ patient)

Person you were exposed to was unmasked

You had close prolonged contact (< 6 feet for > 15 minutes)

Exposure Details

Please list additional context that you find may be helpful

Last Date Worked at OMC?*

Shift Description*

Please list your work schedule for the upcoming week

Comments/Questions/Additional Information

Attestation*

By checking this box, I agree to carefully review the instructions on the next page, and to monitor my email & phone for important communications from the COVID Safety Program.

Send me a copy of my responses

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