EVMS/EVMS Medical Group Exposure Survey

Please complete the survey below.

Thank you!

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Date Submitted

M-D-Y

PLEASE READ CAREFULLY AND FOLLOW INSTRUCTIONS BELOW

Purpose: This survey is intended for individuals who are directly affiliated with EVMS with potential exposure to A COVID-19 positive case due to a prolonged close contact (a cumulative total of 15 minutes or more over a 24-hour period within 6 feet or were exposed to infectious secretions or were present for any duration during an aerosolizing procedure or performed one) in the health care setting when contact with COVID 19 positive case was not expected and employee, research faculty and students were unsure if all appropriate personal protective equipment items were used during the contact in a health care facility or in a social setting or have developed a new onset of symptoms (with or without known exposure) that might be consistent with COVID-19 or with influenza like illness symptoms
You will receive a link at the end of the survey to access the PDF copy of this survey that you can share alerts with your supervisor. Occupational Health or Student Health (for students) will be receiving a copy of your survey.
During completion of this survey you will receive alert (s) that you must follow. If you experience any symptoms, follow symptomatic alert recommendations.

PLEASE READ QUESTIONS CAREFULLY
** This survey is intended for individuals who are directly affiliated with EVMS**

What is your affiliation with EVMS?

* must provide value

Faculty

Staff

Student

Visiting Student

Volunteer

Other

None/No Affiliation

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If you have an EVMS email address, please enter it here, otherwise, enter your preferred email address.

Enter your Email:

I. Employee Contact Information

Last Name:	First Name:
Sex:	DOB:

Address:	Appt:
City:	State:
Phone:	Prefered email:

Age

View equation

Emergency Contact


First Name	Last Name

II. Employee Occupation

Occupation

* must provide value

LPN

Medical Assistant

Other

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Please specify:

* must provide value

Please specify:

* must provide value

Please specify:

* must provide value

Please specify:

* must provide value

III. COVID-19 Case Information

Have you completed;

2 doses of mRNA vaccine (Pfizer/Moderna)
or
1 dose of Johnson&Johnson/Janssen vaccine

* must provide value

Yes No

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Have you received an appropriate booster dose at least two weeks ago?

1 booster dose is recommended for employees 18-49 years old.
2 booster doses are recommended for 50 years old and older.

* must provide value

Yes No

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Have you had a contact to someone with confirmed or suspected COVID-19 for 15 minutes or longer over a 24-hour period being less than 6 feet away OR have you been exposed to infectious secretions OR were you present during or performed an aerosolizing procedure?

* must provide value

Yes No

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At the time of this assessment, is the COVID-19 person:

* must provide value

Confirmed Probable Unknown

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Date of Test (enter an approximate date if exact is not known):

M-D-Y

Patient Tested

Yes No

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Date of Test (enter an approximate date if exact is not known):

M-D-Y

Did the exposure occur at work?

* must provide value

Yes No

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What facility was your exposure to the COVID-19 person:

* must provide value

Please specify:

Is/was the COVID-19 person:

* must provide value

Please specify:

* must provide value

Date of illness onset of COVID-19 case

* must provide value

M-D-Y

Notes:

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Date of contact with the COVID-19 confirmed person (enter an approximate date if exact is not known):

* must provide value

M-D-Y

At any time during the patient's encounter, did you have direct contact with the patient or their secretions/excretions?

* must provide value

Yes No Unsure

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Did you AND a COVID positive person have masks on during the exposure that was 15 minutes or longer and less than 6 feet from each other?

Did you have on a mask AND eyewear protection if the person to whom you were exposed was unmasked?

Yes No

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Were you less than 6 feet of the person with confirmed or suspected COVID-19?

* must provide value

Yes No

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About how many separate times during the patient's encounter did you have contact with the patient or their secretions/excretions?

* must provide value

List date(s) when you had contact with the patient or their secretions/excretions.

Date:

* must provide value

M-D-Y

Date:

M-D-Y

Date:

M-D-Y

Select location of primary work site where you had contact with the patient or patient secretions/excretions:

* must provide value

Lobby

Registration/check-in/front desk

Waiting area

Exam room

Other

Please specify:

* must provide value

Patient room

Unit/Floor

Procedure room

Emergency Room

Other

Room Number:

Please specify:

Drive-through testing center

Community/Free Clinic

Other

Please specify:

At any time during the patient's encounter, did you have prolonged close contact with the patient while the patient was not wearing a mask?

* must provide value

Yes No Unsure

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Did you perform or were present during an aerosolizing procedure?

* must provide value

Yes No

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Were you using ALL APPROPRIATE PPE (N95, goggles, gloves, and gown when you performed an aerosolizing procedure)?

* must provide value

Yes No

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Did you always wear gown and gloves when having extensive body contact with the patient?

* must provide value

Yes No Unsure

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Have you had contact with a COVID-19 positive person outside of work?

* must provide value

Yes No

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Date of Contact (enter an approximate date if exact is not known):

M-D-Y

Date contact was tested for COVID-19 (enter an approximate date if exact is not known):

* must provide value

M-D-Y

Has your contact been released from home isolation?

* must provide value

Yes No Unsure

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Before you had contact with this patient, what level of knowledge did you have about COVID-19?

* must provide value

A lot Some None

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IV. Employee Symptom Assessment

Are you currently experiencing any of the following symptoms (check all that apply)?

* must provide value

Fever (subjective or objective ≥ 100.0 F)

Signs/symptoms of a lower respiratory illness (cough or shortness of breath)

Loss of sense of taste or smell

Sore Throat

Runny Nose

Abdominal Pain

Chills

Vomiting

Nausea

Diarrhea

Headache

Fatigue

General Malaise

Rash

Conjunctivitis

Muscle Aches

Joint Aches

Loss of Appetite

Nose Bleed

Other

N/A - I do NOT have any symptoms

Please specify:

* must provide value

Fever - Date of onset of symptom:

M-D-Y

Signs/symptoms of a lower respiratory illness - Date of onset of symptom:

M-D-Y

Loss of sense of taste or smell - Date of onset of symptom:

M-D-Y

Sore Throat - Date of onset of symptom:

M-D-Y

Runny Nose - Date of onset of symptom:

M-D-Y

Abdominal Pain - Date of onset of symptom:

M-D-Y

Chills - Date of onset of symptom:

M-D-Y

Vomiting - Date of onset of symptom:

M-D-Y

Nausea - Date of onset of symptom:

M-D-Y

Diarrhea - Date of onset of symptom:

M-D-Y

Headache - Date of onset of symptom:

M-D-Y

Fatigue - Date of onset of symptom:

M-D-Y

General Malaise - Date of onset of symptom:

M-D-Y

Rash - Date of onset of symptom:

M-D-Y

Conjunctivitis - Date of onset of symptom:

M-D-Y

Muscle Aches - Date of onset of symptom:

M-D-Y

Joint Aches - Date of onset of symptom:

M-D-Y

Loss of Appetite - Date of onset of symptom:

M-D-Y

Nose Bleed - Date of onset of symptom:

M-D-Y

Please check all symptoms that you are experiencing, and date of onset for each:

Personnel Statement Shazam

Cough

Yes

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Date of Onset:

M-D-Y

Sore Throat

Yes

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Date of Onset 2:

M-D-Y

Shortness of Breath

Yes

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Date of Onset 3:

M-D-Y

Fever

Yes

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Date of Onset 4:

M-D-Y

Do you currently have any of the following risk factors (check all that apply):

* must provide value

≥ 65 years of age

History of chronic lung disease or moderate to severe asthma

History of serious heart conditions

History of chronic treatments/conditions that may leave you immunocompromised (e.g., cancer treatment, smoking, bone marrow and/or organ transplantation, immune deficiencies, poorly controlled HIV/AIDS, prolonged use of corticosteroids and/or other immune weakening medications)

BMI ≥ 40

History of diabetes

History of chronic kidney disease

History of liver disease

Hypertension

N/A

LOW RISK DISPOSITION (NO SYMPTOMS or EXPOSURE)

You have no COVID19-related symptoms or Exposure. If you are currently at work, you may remain at work, continue to perform your regular job duties, and monitor your symptoms. If you are not at work, you may return to work, continue to perform your regular job duties, and monitor your symptoms.

LOW RISK DISPOSITION (EXPOSURE)

Based on the answers you have provided, you might have had an exposure. Since you are Up to Date on COVID vaccines, you may Continue your current activities but should monitor your symptoms for the next 10 days and take your temperature if you feel sick.

To help you keep track of symptoms, you can download the "Asymptomatic Exposed 14 day Symptom Self- Monitoring Form" on the EVMS MyPortal site at: https://myportal.evms.edu/covid-19resources. If you develop any symptoms please complete and submit the EVMS Exposure Survey again and indicate what symptoms you have developed. If you have any questions please contact Human Resources at 446-6043 or for students please contact Student Health at 446-5700.

HIGH RISK DISPOSITION ALERT (EXPOSURE)

You might have had a high-risk exposure. You are cleared to continue your current activities.

Monitor your symptoms for the next 10 days and take your temperature if you feel sick.

Student Health or Occupational Health needs to gather additional information from you, as you might need post exposure COVID testing. Student Health or Occupational Health (whichever is applicable) will reach out to you within one business day if you are involved in direct patient care and within three business days if you are not involved in direct patient care. To help you keep track of symptoms, you can download the “Asymptomatic Exposed 14 day Symptom Self- Monitoring Form” on the EVMS MyPortal site at: https://myportal.evms.edu/covid-19resources.

If you develop symptoms, stay home and notify Occ Health/Student Health via an email: occhealth@evms.edu or studenthealthclinic@evms.edu.

Do not complete another REDCAP survey.

If you do not receive a call during 24-72 hours as outlined above, if you are a student, please contact Student Health at 446-5700. All others please contact Occupational Health at 446-5870.

For urgent questions only AND if it is outside of normal Occupational Health business hours, the exposure pager may be called at (757) 669-1157.

Please note that testing for COVID 19 in the drive through is done by appointment only and conducted Monday through Friday.

HIGH RISK DISPOSITION ALERT (SYMPTOMS)

Alert: You have symptoms that might be consistent with COVID 19 and further evaluation by Student Health for students or Occupational Health for employees is needed. Please do not report to work and notify your supervisor.

Occupational Health or Student Health (whichever is applicable) will reach out to you on the following business day. If you do not receive a call before noon on the following business day, please contact Student Health at 446-5700 if you are a student or all others please contact Occupational Health at 446-5870. For urgent questions only AND if it outside of normal Occupational Health business hours, the exposure pager may be called at (757)669-1157.

Please note that testing for COVID-19 in the drive through is done by appointment only and conducted Monday through Friday.

Low Risk Unvaccinated Alert

You have indicated that have Not Been Vaccinated, have not been exposed and have no symptoms.

You May Continue your current activities and monitor your symptoms.

Please consider getting the COVID 19 vaccine if you are eligible. Monitor your symptoms and complete this survey again if you have an exposure to a COVID 19 case or develop symptoms.

Low Risk Unboosted Alert

You have indicated that have Been Vaccinated but have not received a booster, have not been exposed and have no symptoms.

You May Continue your current activities and monitor your symptoms.

Please consider getting your COVID 19 booster if you are eligible. Monitor your symptoms and complete this survey again if you have an exposure to a COVID 19 case or develop symptoms.


Alert 1	Alert 2	Alert 3	Alert 4	Alert 5	Alert 6
Vaccinated & No Symptoms & No Exposure	Vaccinated and Exposed Socially or at Work	Not Vaccinated & Exposed Socially or at Work	Any Covid Symptoms With or Without Vaccine	Unaccinated & No Symptoms & No Exposure	Unboosted & No Symptoms & No Exposure

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EVMS/EVMS Medical Group Exposure Survey

Have you completed;

2 doses of mRNA vaccine (Pfizer/Moderna) or

1 dose of Johnson&Johnson/Janssen vaccine

Low Risk Unvaccinated Alert

You have indicated that have Not Been Vaccinated, have not been exposed and have no symptoms.

You May Continue your current activities and monitor your symptoms.

Please consider getting the COVID 19 vaccine if you are eligible. Monitor your symptoms and complete this survey again if you have an exposure to a COVID 19 case or develop symptoms.

Low Risk Unboosted Alert

You have indicated that have Been Vaccinated but have not received a booster, have not been exposed and have no symptoms.

You May Continue your current activities and monitor your symptoms.

Please consider getting your COVID 19 booster if you are eligible. Monitor your symptoms and complete this survey again if you have an exposure to a COVID 19 case or develop symptoms.

You have selected an option that triggers this survey to end right now.

2 doses of mRNA vaccine (Pfizer/Moderna)
or