Positive COVID-19 Test Reporting Form

This form should be completed by team members who have tested positive to COVID-19. Any positive test received by the team member including all antigen test results and all PCR test results should be reported using this form. This includes tests obtained through the UMMS self-scheduling strategy as well as tests performed through your PCP, urgent care or other testing sites. The information contained in this form is shared with Employee Health Services and Infection Prevention. Reporting these results allows for identification of possible clusters as well as follow up with COVID positive team members. Reporting positive COVID team members and COVID clusters may be required through the Maryland Department of Health (MDH). Thank you for taking the time to complete this form.


Note: This form was formerly titled "Non-NP Hotline Positive COVID Test Reporting Form" updated 4/3/23

This form is for reporting POSITVE Covid tests only. Check this box if you are reporting a POSITVE Covid test.

Demographics

If you do not have/know the employee ID number, please enter 000.

Employer*
Select
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What is the date you last worked in an UMMS facility?*

Symptoms

Select
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Were you hospitalized as a result of this Covid-19 infection?*

Include name of hospital and dates.

Are you considered moderately or severely immunocompromised (have a weakened immunsystem) due to a medical condition or medical treatment?*

For more information on what conditions or treatments are considered moderately or severely immunocompromising click HERE.


Employee Health needs this information because return to work guidance will vary for individuals who are moderately or severely immunocompromised.

Exposures

Have you had a known or suspected exposure to a COVID-19 case in the last 10 days?*
If YES, Known or Suspected?
Please Select the Type of Exposure
  1. Click the link to access the Employee Event Report blank form
  2. Print and complete the form
  3. Contact your local Employee Health Department for next steps


https://umm.box.com/s/ic72k0uph5zm0cuk75pemz9iutq7n7nm


This information will be shared with employee health and infection prevention for follow up.

Unmasked interactions:

Did you have any unmasked interactions with team members 48 hours prior to your symptom onset or COVID positive result (if no symptoms)?

Assessment

Please select the option that best describes your Covid test:*

Vaccination History (New!)

Has employee received the COVID vaccine?*
How many doses of the vaccine has the employee received?*
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