Today 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 person 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) 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 Macon and Joan Brock Virginia Health Sciences EVMS/EVMS MG at Old Dominion University " **
What is your affiliation with Macon and Joan Brock Virginia Health Sciences at Old Dominion University ?
* must provide value
Faculty
Staff
Student
Visiting Student
Volunteer
Other
Email Address:
* must provide value
Please enter your Macon & Joan Brock Virginia Health Sciences EVMS/EVMS MG at Old Dominion University email, for visiting students, residents and faculty, enter email affiliated with your primary organization.
Email:
Last Name: First Name: Sex: DOB:
Address: Apt: City: State: Phone: Prefered Email:
Last Name:
* must provide value
First Name:
* must provide value
Date of Birth
* must provide value
M-D-Y
View equation
Male Female
Home Street Address:
* must provide value
City:
* must provide value
State:
* must provide value
AL - Alabama AK - Alaska AS - America Samoa AZ - Arizona AR - Arkansas AA - Armed Forces Americas AE - Armed Forces AP - Armed Forces Pacific CA - California CO - Colorado CT - Connecticut DE - Delaware DC - District of Columbia FM - Federated States of Micronesia FL - Florida GA - Georgia GU - Guam HI - Hawaii ID - Idaho IL - Illinois IN - Indiana IA - Iowa KS - Kansas KY - Kentucky LA - Louisiana ME - Maine MH - Marshall Islands MD - Maryland MA - Massachusetts MI - Michigan MN - Minnesota MS - Mississippi MO - Missouri MT - Montana NE - Nebraska NV - Nevada NH - New Hampshire NJ - New Jersey NM - New Mexico NY - New York NC - North Carolina ND - North Dakota MP - Northern Mariana Islands OH - Ohio OK - Oklahoma OR - Oregon PA - Pennsylvania PR - Puerto Rico PW - Palau RI - Rhode Island SC - South Carolina SD - South Dakota TN - Tennessee TX - Texas UT - Utah VA - Virginia VI - Virgin Islands VT - Vermont WA - Washington WI - Wisconsin WV - West Virginia WY - Wyoming
Phone #:
* must provide value
I am affiliated with a non-clinical department.
Yes No
I have direct patient contact in a Clinical Department:
Yes No
I have an administrative position in a Clinical Department.
Yes No
Please describe your responsibilities.
Please describe your clinical responsibilities/patient contact.
Please describe your administrative responsibilities.
Non Clinical Department ER Ophthalmology OB / GYN / UROGYN / MFM IM including specialties PEDS including specialties FM including specialties Otolaryngology RAD/ONC Surgery Dermatology Psychiatry Student Health Occupational Health Inpatient facilities
Occupation
* must provide value
Physician Resident or Fellow Physician assistant/Nurse Practitioner Nurse Receptionist/Patient Registration Front Desk/Administrative Support Student Volunteer Other
LPN RN Medical Assistant Other
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
Have you received an appropriate booster dose at least two weeks ago?
1 booster dose is recommended for individuals 18-49 years old. 2 booster doses are recommended for 50 years old and older.
* must provide value
Yes No
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
At the time of this assessment, is the COVID-19 person:
* must provide value
Confirmed Probable Unknown
Date of Test (enter an approximate date if exact is not known):
Today M-D-Y
Yes No
Date of Test (enter an approximate date if exact is not known):
Today M-D-Y
Did the exposure occur at work?
* must provide value
Yes No
What facility was your exposure to the COVID-19 person:
* must provide value
EVMS Medical Group Clinic SNGH CHKD VA Other
Is/was the COVID-19 person:
* must provide value
Inpatient Outpatient Employee Family member visiting a patient Non-family visitor to a patient Unknown Other
Please specify:
* must provide value
Date of illness onset of COVID-19 case
* must provide value
Today M-D-Y
Date of contact with the COVID-19 confirmed person (enter an approximate date if exact is not known):
* must provide value
Today 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
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?
OR
Did you have on a mask AND eyewear protection if the person to whom you were exposed was unmasked ?
Yes No
Were you less than 6 feet of the person with confirmed or suspected COVID-19?
* must provide value
Yes No
About how many separate times during the patient's encounter did you have contact with the patient or their secretions/excretions?
* must provide value
2 times or less 3 - 5 times 6+ times
List date(s) when you had contact with the patient or their secretions/excretions.
Today M-D-Y
Today M-D-Y
Today M-D-Y
Select location of primary work site where you had contact with the patient or patient secretions/excretions:
* must provide value
Outpatient Clinic Setting Inpatient Setting Other Settings Designated as Patient Care Area
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
Did you perform or were present during an aerosolizing procedure?
* must provide value
Yes No
Were you using ALL APPROPRIATE PPE (N95, goggles, gloves, and gown when you performed an aerosolizing procedure)?
* must provide value
Yes No
(Aerosolizing procedures include open suctioning of airways, sputum induction, cardiopulmonary resuscitation, endotracheal intubation and extubation, non-invasive ventilation (e.g. BiPaP, CPA), bronchoscopy, and manual ventilation).
Did you always wear gown and gloves when having extensive body contact with the patient?
* must provide value
Yes No Unsure
Have you had contact with a COVID-19 positive person outside of work?
* must provide value
Yes No
Date of Contact (enter an approximate date if exact is not known):
Today M-D-Y
Date contact was tested for COVID-19 (enter an approximate date if exact is not known):
* must provide value
Today M-D-Y
Has your contact been released from home isolation?
* must provide value
Yes No Unsure
Before you had contact with this patient, what level of knowledge did you have about COVID-19?
* must provide value
A lot Some None
The option " " can only be selected by itself. Selecting this option will clear your previous selections for this checkbox field. Are you sure?
Are you currently experiencing any of the following symptoms (check all that apply)?
* must provide value
Please specify:
* must provide value
Fever - Date of onset of symptom:
Today M-D-Y
Signs/symptoms of a lower respiratory illness - Date of onset of symptom:
Today M-D-Y
Loss of sense of taste or smell - Date of onset of symptom:
Today M-D-Y
Sore Throat - Date of onset of symptom:
Today M-D-Y
Runny Nose - Date of onset of symptom:
Today M-D-Y
Abdominal Pain - Date of onset of symptom:
Today M-D-Y
Chills - Date of onset of symptom:
Today M-D-Y
Vomiting - Date of onset of symptom:
Today M-D-Y
Nausea - Date of onset of symptom:
Today M-D-Y
Diarrhea - Date of onset of symptom:
Today M-D-Y
Headache - Date of onset of symptom:
Today M-D-Y
Fatigue - Date of onset of symptom:
Today M-D-Y
General Malaise - Date of onset of symptom:
Today M-D-Y
Rash - Date of onset of symptom:
Today M-D-Y
Conjunctivitis - Date of onset of symptom:
Today M-D-Y
Muscle Aches - Date of onset of symptom:
Today M-D-Y
Joint Aches - Date of onset of symptom:
Today M-D-Y
Loss of Appetite - Date of onset of symptom:
Today M-D-Y
Nose Bleed - Date of onset of symptom:
Today M-D-Y
Personnel Statement Shazam
Yes
No
Today M-D-Y
Yes
No
Today M-D-Y
Yes
No
Today M-D-Y
Yes
No
Today M-D-Y
The option " " can only be selected by itself. Selecting this option will clear your previous selections for this checkbox field. Are you sure?
Do you currently have any of the following risk factors (check all that apply):
* must provide value
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) 554-1192.
Please note that testing for COVID 19 in the drive through is done by appointment only and conducted Monday through Friday.
NON-CLINICAL DEPARTMENT HIGH RISK DISPOSITION ALERT (SYMPTOMS)
Alert: You are not involved in direct patient care and have symptoms that might be consistent with COVID 19 or other respiratory infection. Testing for COVID 19 is recommended.
If you feel sick or have fever or other serious symptoms then stay home, contact your healthcare provider for treatment options and notify your supervisor.
If your first COVID 19 test is negative and you continue to have symptoms , repeat test in 48 hours. If your second test is negative, you can return to work when you feel better or when recommended by your healthcare provider.
If you first COVID 19 test is negative, and for at least 24 hours, your symptoms are improving, and if a fever was present, it has been gone without use of a fever-reducing medication in 24 hours or your symptoms resolved, you can return to work. Wear a mask for the next 5 days.
If you test positive you can return to work when, for at least 24 hours, your symptoms are improving, and if a fever was present, it has been gone without use of a fever-reducing medication. Wear a mask for the next 5 days. If you saw a healthcare provider, follow your healthcare provider return to work recommendations.
Please note that testing for COVID-19 may be done using self-tests (at-home tests) or tests done in any healthcare facility.
Employees are required to submit electronically to Occupation Health the following: a photo of the test box, a photo of the test result, date and time of the test, name and DOB or a copy of the test result done at a healthcare facility
If you have further questions, 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 business hours, the exposure pager may be called at (757)554-1192.
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.
CLINICAL DEPARTMENT HIGH RISK DISPOSITION ALERT (SYMPTOMS)
Alert: You are directly involved in patient care and have symptoms that might be consistent with COVID 19 or other respiratory infections. Further evaluation by Student Health for students or Occupational Health for employees is needed. Please do not report to work and notify your supervisor.
Student Health or Occupational 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 for others, please contact Occupational Health at 446-5870 . For urgent questions only AND if outside of normal Occupational Health business hours, the exposure pager may be called at (757)554-1192.
Please note that testing for COVID-19 can be done using self-tests (at-home tests) or tests done in any healthcare facility.
Employees are required to submit electronically to Occupation health the following: a photo of the test box, a photo of the test result, date and time of the test, name and DOB or a copy of the test result done at a healthcare facility
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 4a
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
Non-Clinical
Any Covid Symptoms
Clinical
Unaccinated & No Symptoms & No Exposure
Unboosted & No Symptoms & No Exposure
Alert_1 (No Symptoms & No Exposure)
View equation
Alert_2 (Exposed Socially or at Work)
View equation
Alert_3 (Exposed Socially or at Work)
View equation
Alert_4 Non-Clinical (Any COVID Symptoms)
View equation
Alert_4a Clinical (Any COVID Symptoms)
View equation
Alert_5 (No Symptoms & No Exposure)
View equation
Alert_6 (No Symptoms & No Exposure)
View equation