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

Check this box:

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

Check this box:

Demographics

Employee LAST Name

Employee FIRST Name

Employee ID #

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

Date of Birth

mm/dd/yyyy

Best Employee Phone Number

Best Employee Email Address

Job Title

Department

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

1. Click to enter the date below (best approximation)

2. Click if team member has not been onsite

Symptoms

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

Yes

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.

Yes

Exposures

Have you had a known or suspected exposure to a COVID-19 case in the last 10 days?

Yes

Unknown

Exposure Details

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)?

Yes

Assessment

Please select the option that best describes your Covid test:

Yes (Home Antigen)

Yes (Self-Scheduled UMMS PCR Test)

Yes (Scheduled Outside UMMS e.g. doctor's office, urgent care, CVS, etc.)

Yes (Roving Cart)

What is the date of your positive Covid test?

mm/dd/yyyy

Vaccination History (New!)

Has employee received the COVID vaccine?

Yes

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