COVID-19 Employee & Medical Staff Screening Form

Employees and Medical Staff,

Please fill out this form if:

  • You have come in contact with a (+) COVID-19 person, or
  • You currently are experiencing symptoms of an influenza-like illness.

Based on the information you provide, a Tulane Health Employee will be in touch with you to follow up . The information you provide on this form will be secure and will remain private.

If you have come in contact with a (+) COVID-19 person and are currently experiencing fever, cough, sore throat, runny nose, or difficulty breathing, please call your healthcare provider immediately and let your supervisor know. Do not come in to work.

After you have completed the form if you still have questions or if unable to complete the online form, call 504-988-HEAL.

    I am screening for (must choose one)
    Contact with COVID-19Symptoms of influenza-like illness

    Prolonged close contact? (Within 6 ft for at least 10 consecutive minutes)
    YesNoNot Applicable

    The following questions are to be answered if your COVID-19 exposure was in the hospital.

    What is your relation to the person with COVID-19?
    PatientCo-workerNot Applicable

    Were you present for aerosol- or cough-generating procedure (cardio-pulmonary resuscitation, intubation, extubation, non-invasive positive pressure ventilation, bronchoscopy, nebulizer therapy, sputum induction, nasogastric tube placement, open suctioning of airway)?
    YesNoNot Applicable

    Did you have direct contact with the patient’s body fluids/secretions such as being coughed on or cleaning the patient after toileting?
    YesNoNot Applicable

    Was the patient/co-worker wearing a face mask?
    YesNoNot Applicable

    Were you wearing a face mask?
    Surgical MaskN-95PAPRNo MaskNot Applicable

    Were you wearing eye protection?
    YesNoNot Applicable

    Were you wearing a gown?
    YesNoNot Applicable

    Were you wearing gloves?
    YesNoNot Applicable

    Current Symptoms of an influenza-like illness. If you chose symptoms of influenza-like illness, please check the following symptoms you are experiencing.
    Fever Higher than 100ChillsCoughSore ThroatShortness of BreathAches & PainsDiarrheaVomiting

    Have you sought care from your personal physician?

    Do you have any chronic medical conditions (lung disease, heart disease, diabetes, current chemotherapy) which would put you at risk?

    We looking forward to helping you and will be in touch soon.

    ~ Your Tulane Living Well Care Team