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Employee | Health Services COVID-19 Symptom Report
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Name
Title
Title
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Miss
Ms
Mr
Mrs
Dr
Other…
Enter other…
First Name
Last Name
ETBU email address
Phone
What date were you exposed?
Who exposed you to COVID?
Department
Select One
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Employee positive for COVID-19
Employee experiencing symptoms of COVID-19
Employee EXPOSED to someone who has symptoms or someone who is positive for COVID-19
Employee reports someone at home EXPOSED to someone who tested positive or has symptoms
Please select all that apply
Fever (100° F or higher)
Cough
Shortness of breath/difficulty breathing
Headache
Sore throat
New loss of taste or smell
body chills
extreme level of fatigue
body/muscle aches
travel in the last 14 days to any region affected by COVID-19
What date did your symptoms start?
What date did you have your test?
Where did you have your test?
What date did your symptoms start?
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