DCIU Employee Self-Reporting Health Form

Delaware County Intermediate Unit Employee Health Self-Reporting Form

Your Name*

First Name

Last Name

Your Email address*

Please select your work location*

Please provide your location*

Please select your program/department*

Please select your job title*

Provide your job title*

Employee or Contractor?*

Employee Contractor

What is your employment agency name?*

Who is the name of the agency's contact person?*

What is the agency's phone number?*

What is the agency's email address?*

Please select your supervisor?*

Please select your director?*

Your Home Address*

Address Line 1

City

State

ZIP Code

Your Phone Number*

Please select a scenario*

Please contact your supervisor before returning to work.

Reason for testing*

I had previously submitted a self-reporting form and was directed to submit results Other

Please provide an explanation:*

When did you get tested for COVID-19?*

Please upload test results*

No File Chosen

File uploads may not work on some mobile devices.

Your Date of Birth*

Do you have symptoms?*

Yes No

Please list all work locations you visited 2 days prior to date of symptom(s) onset and thereafter*

Please list all work locations you visited 2 days prior to the test date and thereafter*

Who were you in close contact with (6 feet or less for 15 minutes or longer) while at work, 2 days prior to the onset of symptoms and thereafter (please list full names- staff and students)?*

Close contact means being within 6 feet for 15 minutes or more, with or without a mask.

While at work, did you have your face mask on at all times?*

Yes No

If not, please explain*

Explanation*

Please provide details.

When did COVID-19 symptoms first appear?*

When was your last day at work?*

When did you get tested for COVID-19?*

When did you receive your COVID-19 test results?*

Please upload a copy of your COVID-19 test results

No File Chosen

File uploads may not work on some mobile devices.

*Have you been vaccinated?*

Yes No

What brand of vaccine did you receive?*

Johnson and Johnson Moderna or Pfizer

Date of vaccination*

First Dose Received on*

Second Dose Received on

Have you been vaccinated?*

Yes No

Do you have any COVID-19 symptoms?*

Yes No

Has your supervisor discussed Test-To-Stay program with you?*

Yes No

What Brand of vaccine did you receive?*

Johnson & Johnson Moderna or Pfizer

Date of Vaccine*

First Dose Received on*

Second Dose Received on*

Did you receive a booster COVID-19 vaccine?*

Yes No

Date booster was received*

What brand booster vaccine did you receive?*

Johnson & Johnson Moderna Pfizer

Have you been fully vaccinated?*

Yes No

What brand of vaccine did you receive?*

Johnson and Johnson Moderna or Pfizer

Date of vaccination*

First Dose Received on*

Second Dose Received on*

Did you receive a booster COVID-19 vaccine?*

Yes No

Date booster was received*

What brand booster vaccine did you receive?*

Johnson & Johnson Moderna Pfizer

Is the person a member of your household?*

Yes No

At the time of contact, was the person symptomatic?*

Yes No

Date the person's symptoms began*

Date the person was COVID-19 tested (not the date of the results)*

I was within 6 feet for 15 minutes or more*

Yes No

I provided care at home to the person with COVID-19*

Yes No

I had direct physical contact with the person with COVID 19 (hugged or kissed them)*

Yes No

Who were you in close contact with who tested Positive with COVID-19*

When did the household member receive the positive test result?*

When did the household member get tested?*

When was the last time you were in close contact with the infected person?*

Are you able to isolate yourself from the infected member of your house?*

Yes No

Have you scheduled the COVID-19 test?*

Yes No

Have you scheduled the COVID-19 test?*

Yes No

Please provide the scheduled date of your test.*

What is the date of the COVID-19 test?*

Are you, the employee, sick?*

Yes No

Date of symptoms(s) onset*

Please list all work locations you visited 2 days prior to date of symptom(s) onset and thereafter*

Have you tested positive for COVID 19 in the past 3 months, recovered, and have not developed any new symptoms?*

Yes No

Have you tested positive for SARS-CoV-2 antibodies in the past 3 months, and have not developed any new symptoms?*

Yes No

Have you been in contact with anyone with COVID-19? *

Yes No

When was the last time you were in close contact with the infected person?*