COVID-19 Employee Screening Tool

This screening tool is designed to allow MSK employees to report positive results of COVID-19 performed outside MSK. In addition to reporting your positive COVID-19 test through the screening tool, please be sure to notify your manager of your positive test.

The best telephone number to reach you at

Details have already been provided for this case. Are you sure you want to resubmit information?

Yes

No

Exposure Code: Unique code found in communication from Infection Control/EHWS (Ex. 12345 or E12345)

What was your test result?

Negative Positive

Details have already been provided for this case. Are you sure you want to resubmit information?

Yes

No

Do you have symptoms?

Yes

No

When did your symptoms start?

Have you been onsite since

Yes

No

Yes

No

Did you document your in-person patient interactions in CIS?

Yes

No

Please explain.

Did you act as a sitter or companion for a patient?

Yes

No

Are you experiencing any of the following new or worsening symptoms?

Fever/chills OR cough OR shortness of breath OR body aches OR loss of sense of smell or taste OR sore throat.

Yes, Symptomatic No, Asymptomatic

Are you fully vaccinated? Fully vaccinated means you received your final dose (2nd dose of a 2 ?dose vaccine or single dose of a 1-dose vaccine) more than 2 weeks ago.

Yes No

MSK currently does not have documentation of your COVID-19 vaccination. Please scan or take a photo of your vaccine record and email it to Covid19doc@mskcc.org with your full name and employee ID number.

Have you recently been exposed to someone you think may have COVID-19?

Note: Infected people are contagious 2 days before symptoms begin or 2 days before date of positive test if asymptomatic.

Yes, I was exposed to someone with COVID-19 (Primary exposure)

No, I was not exposed to someone with COVID-19

No, but I was exposed to someone who was exposed to someone with COVID-19. (Secondary exposure)

Was the exposure from someone you live with?

Yes No

What was the location of exposure?

Was the exposure to someone who was a:

Employee Patient Visitor / Vendor

Do you know who you were exposed to?

Yes No

If this was a work exposure, please provide their name

Check all that apply:

You had close contact with the person with COVID-19?

Close contact is defined as either being within 6ft (2m) for a total of more than 15 min over the course of one day or having unprotected direct contact with infectious secretions (e.g., coughing).

The infected person was wearing a mask.

You were wearing a mask.

Name

MRN* if known

Were you present in the room for procedures that generate aerosols or during which respiratory secretions are likely to be poorly controlled (e.g., cardiopulmonary resuscitation, intubation, extubation, bronchoscopy, nebulizer therapy, sputum induction)?

Yes No

Check all that apply:

You were wearing an N95 mask.

You were wearing eye protection, face shield or goggles.

You were wearing a gown.

You were wearing gloves.

Check all that apply:

You had close contact with the person with COVID-19?

Close contact is defined as either being within 6ft (2m) for a total of more than 15 min over the course of one day or having unprotected direct contact with infectious secretions (e.g., coughing).

The patient was wearing a mask.

You were wearing a facemask.

You were wearing eye protection, face shield or goggles.

Have you had a documented COVID-19 illness in the last 4 months? Note: Positive swab test

Yes No

Please only click submit once.