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.

 
 
 
 
 
Phone
 
 

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

 

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