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Employee | Health Services COVID-19 Symptom Report
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Name
Title
Title
- None -
Miss
Ms
Mr
Mrs
Dr
Other…
Enter other…
First Name
Last Name
ETBU email address
Phone
Is a member of your household also employed at ETBU?
- Select -
Yes
No
Please add the household member's name.
What date were you exposed?
Who exposed you to COVID?
Department
Select One
- Select -
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
Other…
Enter other…
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?
Have you ever tested positive for COVID?
- Select -
Yes
No
Date tested positive for COVID? (documentation required)
Have you been vaccinated for Covid-19?
- Select -
Yes
No
What date did you receive the vaccine?
Please send proof of documentation that you received the vaccine to
healthservices@etbu.edu
.
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