Vendor - Covid-19 Positive Exposure Form

Vendor - Covid-19 Positive Exposure Form

This tool is used to collect data from vendor representatives who had cold symptoms and visited one of Ascension's sites of care before being confirmed with COVID-19. This information will be used to track potential exposure.

Name*

Title*

Company*

Email Address*

Phone Number*

Phone

Symplr ID Number*

Positive COVID-19 Test*

Have you had a positive COVID-19 test? (Yes/No)

Select

Date of Positive Test*

If you have tested positive for SARS CoV-2, the causative agent of COVID-19, what date did you test positive?

COVID-19 Symptoms*

Have you experienced COVID-19 Symptoms? (Yes/No)

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Date Symptoms Began*

If you have experienced any symptoms (even mild) of any illness (scratchy throat, body aches, cough), when did you symptoms begin?

Date Symptoms Ended

If you experienced any symptoms (even mild) of any illness (scratchy throat, body aches, cough), when did your symptoms end?

PLEASE READ ALL OPTIONS CAREFULLY*

Were you in an Ascension facility during any of the following?: 1) Two days prior to your onset of COVID-19 symptoms, 2) while you had COVID-19 symptoms, 3) within 10 days of COVID-19 symptoms first appearing, 4) within 24 hours of COVID-19 symptoms resolution, 5) two days prior to testing positive for COVID-19, or 6) within 10 days of testing positive for COVID-19

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Dates at Ascension Facility*

If you were in an Ascension facility either two days prior to, or any time after your onset of symptoms, what were the dates? Please format date(s) mm/dd/yy; separating multiple dates with a comma.

Facility Visited*

If you visited multiple facilities, complete a separate form for each facility

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Department(s) Visited*

Please select all departments visited, if other add in blank below.

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Other Department(s) Visited*

Please fill in any departments visited not listed in above drop down menu.

Were you within 6 ft of any associate for 15 minutes or more while unmasked?*

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Name(s) and Date(s) of Associate Encounter(s)*

Please list their names and date of encounter. Please format as follows: Name, mm/dd/y: Name, mm/dd/yy; Name, mm/dd/yy

Were you within 6 ft of any patient for 15 minutes or more while unmasked?*

If yes, you will be contacted for more information.

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