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This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

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Required format:

/^((0?[1-9])|([1-8][0-9])|(9[0-8]))[0-9]{3}$/

/^((29([-\/])02\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1\d|2[0-8])([-\/])(0[1-9]|1[012]))|((29|30)([-\/])(0[13-9]|1[012]))|(31([-\/])(0[13578]|1[02])))(\11|\15|\18)\d{4}))$/

/^((02([-\/])29\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1[012])([-\/])(0[1-9]|1\d|2[0-8]))|((0[13-9]|1[012])([-\/])(29|30))|((0[13578]|1[02])([-\/])31))(\11|\15|\19)\d{4}))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31))))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31)))) (\d|[0-1]\d|[2][0-3]):[0-5]\d$/

/^(?!\.)((?!.*\.{2})[a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF!#$%&'*+\-/=?^_`{|}~\d]+)(\.[a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF!#$%&'*+\-/=?^_`{|}~\d]+)*@(?!\.)([a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF\-\.\d]+)((\.([a-zA-Z\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF]){2,63})+)$/i

/^[-+]?\b\d+\b$/

/^[a-z]+$/i

/^\d{10}$/

/^[a-z0-9-_]+$/i

/^[-+]?[0-9]*\.?[0-9]+([eE][-+]?[0-9]+)?$/

/^-?\d+,\d$/

/^-?\d+\.\d$/

/^-?\d+,\d{2}$/

/^-?\d+\.\d{2}$/

/^-?\d+,\d{3}$/

/^-?\d+\.\d{3}$/

/^-?\d+,\d{4}$/

/^-?\d+\.\d{4}$/

/^[-+]?[0-9]*,?[0-9]+([eE][-+]?[0-9]+)?$/

/^($0[2-8]$|0[2-8])\s*\d{4}\s*\d{4}$/

/^(?:$?([2-9]0[1-9]|[2-9]1[02-9]|[2-9][2-9][0-9])$?)\s*(?:[.-]\s*)?([2-9]\d{2})\s*(?:[.-]\s*)?(\d{4})(?:\s*(?:#|x\.?|ext\.?|extension)\s*(\d+))?$/

/^\d{4}$/

/^[ABCEGHJKLMNPRSTVXY]{1}\d{1}[A-Z]{1}\s*\d{1}[A-Z]{1}\d{1}$/i

/^(0[1-9]|[1-9]\d)\d{3}$/

/^\d{3}-\d\d-\d{4}$/

/^([0-9]|[0-1][0-9]|[2][0-3]):([0-5][0-9])$/

/^[0-5]\d:[0-5]\d$/

/^[0-9]{4,9}$/

/^\d{5}(-\d{4})?$/

w4wpJhrziDaT3NRFoMI5vjxtkvpIUBHDf9W4hrzNtoBNUJJ53G2d86Dw7fXw3ErEhgpETWKdxiG2hqW3LMGb26VI

COVID-19 Employee Occupational Health Screening Questionnaire

This survey is being used in lieu of calling Occupational Health. This process was developed to make reporting of COVID-19 symptoms, exposures, and test results more efficient for employees and Occ Health.

M-D-Y

Yes

reset

Yes

reset

Expand

Fever or chills

Cough

Shortness of breath or difficulty breathing

Fatigue

Muscle or body aches

Headache

New loss of taste or smell

Sore throat

Congestion or runny nose

Nausea or vomiting

Diarrhea

I'm not currently experiencing any symptoms

M-D-Y

Yes

reset

M-D-Y

Expand

Positive

Negative

Pending

reset

M-D-Y

Yes

reset

Expand

Yes

Yes

Yes

Yes

M-D-Y

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The CDC recommends that you quarantine due to your exposure to COVID-19 through the date in the text box on the right. However, since you are a critical employee, you may continue to work as scheduled until you are contacted by Occupational Health for further direction.

Occupational Health will contact you to discuss the possibility of continuing to work throughout your quarantine period. This is because you are a critical worker. We have established a protocol for frequent testing for critical workers to allow them to work during quarantine. We ask that when you are not at work, you quarantine at home.

If you develop symptoms associated with COVID-19 or receive a COVID-19 diagnosis, do not report to work and immediately fill out this survey again to update us.

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The CDC does not recommend that you isolate or quarantine at this time because you do not have any symptoms associated with COVID-19, nor have you been diagnosed with COVID-19, nor have you been in close contact with someone who has confirmed COVID-19. You can return to work immediately. If you develop symptoms associated with COVID-19 or receive a COVID-19 diagnosis, please stay home and immediately fill out this survey again to update us.

Please sign to confirm that you have read and understand these instructions.

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STAY HOME & DO NOT COME TO WORK.

The CDC recommends that you stay home and isolate due to your symptoms, and possible need for quarantine. Occupational Health will contact you to arrange COVID-19 testing. If you receive a COVID-19 diagnosis, please stay home and immediately fill out this survey again to update us.

Please sign to confirm that you have read and understand your home isolation instructions and will not return to work until approved by Occupational Health.

Add signature

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STAY HOME & DO NOT COME TO WORK.

The CDC recommends that you stay home and isolate due to your symptoms. Because of your contact, you may also need to be under quarantine restrictions. Occupational Health will contact you to determine time of isolation and quarantine.

Please sign to confirm that you have read and understand your home isolation and quarantine instructions and will not return to work until approved by Occupational Health.

Add signature

STAY HOME & DO NOT COME TO WORK.

The CDC recommends that you stay home and isolate due to your symptoms. Occupational Health will contact you to arrange COVID-19 testing. If you receive a COVID-19 diagnosis, please stay home and immediately fill out this survey again to update us.

Please sign to confirm that you have read and understand your home isolation instructions and will not return to work until approved by Occupational Health.

Add signature

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You have selected an option that triggers this survey to end right now. To save your responses and end the survey, click the button below to do so. If you have selected the wrong option by accident and do not wish to leave the survey, you may click the other button below to continue, which will also remove the value of the option you just selected to allow you to enter it again and continue the survey.

The response has now been removed for the last question for which you selected a value. You may now enter a new response for that question and continue the survey.