COVID-19 Partner Screening Form

Please complete the COVID-19 screening form. You will be provided further guidance once you complete the online information. Based on the most recent CDC guidance.

Below is the overview of the Green, Yellow, and Red directions based on your answers to the COVID-19 screening form:
“Green” Partner is able to work and no further action is required.

“Yellow” Partner may stay at work, ensure strict mask wearing AND needs to have a negative COVID-19 test as soon as possible. If the COVID-19 test result is positive the partner should leave work immediately. An individual from Employee Health will follow-up with these partners within 48 business hours.

“Red” Partner should NOT come to work or leave work immediately. An individual from Employee Health will follow-up with these partners within 24 business hours.

Partner/Employee ID (e.g. 60000xxxx, or 900xxxx): *

Use only numbers in this field.
Include all leading zeroes.
Name: Name: * First Last
Your Mercyhealth Email: *

Email address must end with @mhemail.org
Your Direct Leader Mercyhealth Email: *

Email address must end with @mhemail.org
Your Phone: Your Phone: * - ### - ### ####
Location: *
Department Name: *
Job Title: *
COVID-19 Related Questions:

Tell us about your vaccination history and how you are feeling today? *
	Yes	No
Are you fully vaccinated? (two doses Pfizer/Moderna; single dose J&J)	Are you fully vaccinated? (two doses Pfizer/Moderna; single dose J&J)Yes	Are you fully vaccinated? (two doses Pfizer/Moderna; single dose J&J)No
Have you received a booster shot?	Have you received a booster shot?Yes	Have you received a booster shot?No
Have you been exposed to a COVID-19 positive individual for longer than 15 minutes within the last 24 hour AND without proper PPE (Personal Protective Equipment such as Surgical Mask or N-95)?	Have you been exposed to a COVID-19 positive individual for longer than 15 minutes within the last 24 hour AND without proper PPE (Personal Protective Equipment such as Surgical Mask or N-95)?Yes	Have you been exposed to a COVID-19 positive individual for longer than 15 minutes within the last 24 hour AND without proper PPE (Personal Protective Equipment such as Surgical Mask or N-95)?No
Do you currently exhibit any of the following symptoms such as fever greater than 100.4, cough, shortness of breath, new episode of moderate/severe nasal congestion?	Do you currently exhibit any of the following symptoms such as fever greater than 100.4, cough, shortness of breath, new episode of moderate/severe nasal congestion?Yes	Do you currently exhibit any of the following symptoms such as fever greater than 100.4, cough, shortness of breath, new episode of moderate/severe nasal congestion?No
Have you had a new COVID-19 test and tested POSITIVE in the last 5 days (if the test is pending, please answer NO)?	Have you had a new COVID-19 test and tested POSITIVE in the last 5 days (if the test is pending, please answer NO)?Yes	Have you had a new COVID-19 test and tested POSITIVE in the last 5 days (if the test is pending, please answer NO)?No
Have you tested positive for COVID-19 within the range of 5 to 90 days?	Have you tested positive for COVID-19 within the range of 5 to 90 days?Yes	Have you tested positive for COVID-19 within the range of 5 to 90 days?No

Please tell us the date of your positive COVID-19 test? Please tell us the date of your positive COVID-19 test? * / MM / DD YYYY
Please provide us with any additional information that you feel may be relevant or any other symptoms that you are experiencing:

COVID-19 Partner Screening Form

COVID-19 Partner Screening Form

COVID-19 Related Questions: