This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range.

The value you provided is outside the suggested range.

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

/^((0?[1-9])|([1-8][0-9])|(9[0-8]))[0-9]{3}$/

/^((29([-\/])02\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1\d|2[0-8])([-\/])(0[1-9]|1[012]))|((29|30)([-\/])(0[13-9]|1[012]))|(31([-\/])(0[13578]|1[02])))(\11|\15|\18)\d{4}))$/

/^((02([-\/])29\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1[012])([-\/])(0[1-9]|1\d|2[0-8]))|((0[13-9]|1[012])([-\/])(29|30))|((0[13578]|1[02])([-\/])31))(\11|\15|\19)\d{4}))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31))))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31)))) (\d|[0-1]\d|[2][0-3]):[0-5]\d$/

/^(?!\.)((?!.*\.{2})[a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF!#$%&'*+\-/=?^_`{|}~\d]+)(\.[a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF!#$%&'*+\-/=?^_`{|}~\d]+)*@(?!\.)([a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF\-\.\d]+)((\.([a-zA-Z\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF]){2,63})+)$/i

/^[-+]?\b\d+\b$/

/^[a-z]+$/i

/^\d{10}$/

/^[a-z0-9-_]+$/i

/^[-+]?[0-9]*\.?[0-9]+([eE][-+]?[0-9]+)?$/

/^-?\d+,\d$/

/^-?\d+\.\d$/

/^-?\d+,\d{2}$/

/^-?\d+\.\d{2}$/

/^-?\d+,\d{3}$/

/^-?\d+\.\d{3}$/

/^-?\d+,\d{4}$/

/^-?\d+\.\d{4}$/

/^[-+]?[0-9]*,?[0-9]+([eE][-+]?[0-9]+)?$/

/^($0[2-8]$|0[2-8])\s*\d{4}\s*\d{4}$/

/^(?:$?([2-9]0[1-9]|[2-9]1[02-9]|[2-9][2-9][0-9])$?)\s*(?:[.-]\s*)?([2-9]\d{2})\s*(?:[.-]\s*)?(\d{4})(?:\s*(?:#|x\.?|ext\.?|extension)\s*(\d+))?$/

/^\d{4}$/

/^[ABCEGHJKLMNPRSTVXY]{1}\d{1}[A-Z]{1}\s*\d{1}[A-Z]{1}\d{1}$/i

/^(0[1-9]|[1-9]\d)\d{3}$/

/^\d{3}-\d\d-\d{4}$/

/^([0-9]|[0-1][0-9]|[2][0-3]):([0-5][0-9])$/

/^[0-5]\d:[0-5]\d$/

/^[0-9]{4,9}$/

/^\d{5}-\d{4}$/

/^\d{5}(-\d{4})?$/

9IGha8WM9uRpxHWCNJtS8fayGeVDm8Nz

EVMS/EVMS Medical Group Travel Survey

Please complete the survey below.

Thank you!

The option "" can only be selected by itself. Selecting this option will clear your previous selections for this checkbox field. Are you sure?

Yes

reset

Yes

reset

Car

Plane

Cruise ship or riverboat

Train

Bus

Other

Yes

reset

Travel Table

M-D-Y

Yes

reset

Flight Layover(s)/Transfer

M-D-Y

Yes

reset

Domestic Travel

M-D-Y

Yes

reset

Cruise Information

M-D-Y

Yes

reset

You had an exposure during your travel.

Please complete and submit the EVMS/EVMS Medical Group Exposure Survey.

Fever (100.4 degrees or higher)

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

M-D-Y

Mild

Severe

reset

M-D-Y

Mild

Severe

reset

Over 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 - I do NOT have any risk factors

Lung disease

Cancer

Hypertension

Heart Failure

Cardiovascular disease

Renal disease

Liver disease

Immunocompromised conditions

Sickle Cell Disease

Pregnancy

Yes

reset

Work

Home

Visiting Medical Facility

Public Gathering

Airport

Outside

Other

Residential Care Facility

Hospital

Medical Clinic (not working)

Other

reset

Yes

reset

Clinical Setting

Airplane

Airport

Public

Inside

Outside

Other

Cough

Shortness of Breath

Appeared "un-well"

Other

Yes

reset

Clinical Setting

Airplane

Airport

Public

Inside

Outside

Other

Cough

Shortness of Breath

Appeared "un-well"

Other

You have traveled internationally or domestically within the last 2 weeks. Travel increases your chances of getting and spreading COVID-19. There are no quarantine requirements for people arriving to the Commonwealth from other U.S. or international locations, as of October 7, 2020. Watch your health and take your temperature if you feel sick. If you choose to you can download the “Asymptomatic Exposed 14 day Symptom Self- Monitoring Form” on the EVMS MyPortal site at: https://myportal.evms.edu/covid-19resources/ to help you keep track of your symptoms. Should you develop any symptoms within 2 weeks of your return date please complete and submit the EVMS/EVMS Medical Group Exposure Survey

If you have any questions please contact Human Resources at 446-6043 or for students please contact Student Health at 446-5700.

You have traveled internationally or domestically within the last 2 weeks and/or 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 complete and submit the EVMS/EVMS Medical Group Exposure Survey.

Please do not report to work and notify your supervisor. If you are currently at work, leave work immediately 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.

You have selected an option that triggers this survey to end right now. To save your responses and end the survey, click the button below to do so. If you have selected the wrong option by accident and do not wish to leave the survey, you may click the other button below to continue, which will also remove the value of the option you just selected to allow you to enter it again and continue the survey.

The response has now been removed for the last question for which you selected a value. You may now enter a new response for that question and continue the survey.