COVID-19 Screening Application

Please respond to the following questions based on your current health status, reporting symptoms that are over and above what is normal for you, or exposures in which appropriate infection control measures were not in place or followed during an encounter with an individual positive for COVID-19 or exhibiting symptoms suspicious of COVID. If you have received a COVID-19 vaccine within the past 48 hours and have developed fever or chills as a common side effect of the vaccine, especially following the second dose, wait 24 hours until the fever has passed and attempt to take this screening survey again. If you have been diagnosed with or been advised by a licensed healthcare provider that you are suspected to have COVID-19 and have not already obtained clearance from Employee Health to return to work, you may not work until official clearance has been granted.

This survey is not intended to be used as a tool to clear staff experiencing symptoms of other diseases. Please reference the Healthcare Worker Disclosure and Management of Communicable Diseases Policy. If your symptoms worsen or progress, or if your symptoms indicate that you should not be working per this policy, please seek evaluation.

First Name:

Last Name:

Check this box if you are a Baptist Health Contractor, Independent Licensed Provider, Vendor or other Authorized Individual not employed directly by Baptist Health.

Employee ID:

Any symptoms or exposures already cleared by Employee Health can be ignored unless symptoms have worsened or are inconsistent with previously reported symptoms.

Please indicate your vaccine status:

		Unvaccinated
		Partially Vaccinated
		Vaccinated
		Boosted

If you have not already done so, please upload a copy of your booster information to ReadySet. Visit the ReadySet page on the Employee Health Services SharePoint site for instructions if needed.

Check here if you are reporting that you have recently been diagnosed with or tested positive to COVID-19 within the past 14 days)

Yes	No

List the date your positive COVID test was collected or date of your diagnosis.

		1.) I’ve already been cleared to return to work from this infection
		2.) This is the first time I am reporting this infection to Baptist Health

Have you been in contact (i.e., come within 6 feet for a cumulative 15 minutes over a 24-hour period) with anyone in the past 14 days that has (i) tested positive for COVID-19 and/or (ii) shown signs of COVID-19 (excluding any patients with whom you have been in contact within your normal duties wearing proper PPE) while you were not wearing a respirator or well-fitting face mask and eye protection?

Yes	No

COVID-19 Screening Application- Workforce