Survey Date (auto populates, hidden from public survey)
Today M-D-Y
Children's is committed to a culture that prioritizes staff and patient safety. The following form will aid in the assessment of your risk for COVID-19. COVID-19 Hub First Name* must provide value
Last Name* must provide value
Cell Phone Number* must provide value
Work Number* must provide value
Children's Email* must provide value
Personal Email* must provide value
Manager Name* must provide value
Manager Phone Number
Manager Email* must provide value
I am currently a: Employee: Has an active Employee ID and receives checks from Children's payroll. * must provide value
Children's Employee Non-Employee Children's Prehire Pediatric Institute (PI) Children's Employee
Non-Employee
Children's Prehire
Pediatric Institute (PI)
Who was your recruiter? * must provide value
Please specify your role at Children's. * must provide value
Please select the position that best applies to you. (HIDDEN)* must provide value
Physician Nurse Practitioner Anesthetist Nurse Respiratory Therapist Security Registration Associate Social Worker Patient Safety Sitter Food Service Environmental Services Surgical Tech MRI Tech Patient Care Tech Patient Care Specialist Scheduler Other
Other. Please specify:* must provide value
Job Title* must provide value
Please enter your title as it appears on your badge.
Employee ID* must provide value
Computer Login or Epic ID:* must provide value
A User ID is any numbers (and any letters) used when logging into your CHOA computer. For non-employees, this is likely your first initial, last initial, and the last 4 of your SS#
Please select your home campus:* must provide value
Egleston Scottish Rite Hughes Spalding Support Building Park West Park North Alpharetta Atlanta Plastic Surgery Canton Center for Advance Pediatrics (CAP) Chamblee Urgent Care Cobb CPG Data Center Distribution Warehouse Duluth (Sports) East Cobb Emory Children's Center Fayette Forsyth Gwinnett Hamilton Mill Hudson Bridge Ivy Walk Meridian Mark Marcus Autism Center Mt. Zion MOB N. Druid Hills North Point Sandy Plains Satellite Boulevard. Snellville Suwanee Town Center Webb Bridge Other
Other. Please specify:* must provide value
Unit at Egleston:* must provide value
4 East 4 West 5 West 5 East Aerodigestive Clinic Aflac Inpatient Aflac Clinic Apheresis Case Management Cardiac Cath Lab Central Staffing CICU CPG CSU CT Surgery Day Surgery Diabetes Education ED NICU Non-Invasive Cardiology OR Ostomy Services PACU PICU Pre-Post Recovery Pulmonary HTN Clinic Radiology-Sedation Short Stay Unit Special Procedures TICU Transplant Clinic Trauma Services Transport Services TSU Vascular Access Pharmacy Laboratory CACU Radiology Other
Unit at SR* must provide value
1st Floor 2nd Floor 3rd Floor 4th Floor 4 South Aflac Inpatient Aflac Clinic Case Management Central Staffing CIRU Day Surgery Diabetes Education Emergency Department Judson Hawk Clinics Meridian Mark NICU Ostomy Services OP PACU PICU Radiology-Sedation Special Procedures Lab TICU Trauma Services Transport Services Vascular Access 975 Johnson Ferry Road Pharmacy Laboratory CACU Radiology Other
Unit at HS* must provide value
Clinics ED Inpatient Other
Other. Please specify. * must provide value
Street Address* must provide value
Street Address Line 2
City * must provide value
State* must provide value
Zip Code* must provide value
County* must provide value
Date of Birth* must provide value
Today M-D-Y
Gender* must provide value
Male
Female
Other
Race* must provide value
White Black or African American American Indian or Alaska Native Asian Indian Chinese Filipino Japanese Korean Vietnamese Other Asian Native Hawaiian Guamanian or Chamorro Samoan Other Pacific Islander
Please specify other race.* must provide value
Ethnicity* must provide value
No, not of Hispanic, Latino/a, or Spanish origin Yes, Mexican, Mexican American, Chicano/a Yes, Puerto Rican Yes, Cuban Yes, another Hispanic, Latino, or Spanish origin
Age
View equation
Are you filling out this form because you reported symptoms at a Children's Wellness Screening?* must provide value
Yes No
Were you asked to return home?* must provide value
Yes No
Did Infection Prevention ask you to fill out this form due to a potential exposure investigation?* must provide value
Yes No
Have you received individual, direct guidance regarding isolation, quarantine and/or monitoring from a representative of a public health entity or from another healthcare system?* must provide value
Yes No
What was the facility? Select all that apply.* must provide value
Department of Public Health
Hospital System
Primary Care
Urgent Care
Other
Department of Public Health
Hospital System
Primary Care
Urgent Care
Other
Other. Please specify:* must provide value
If yes, please specify the guidance that you were given.* must provide value
Was this guidance given verbally or in writing? * must provide value
Verbally In Writing
Did you receive a copy of this guidance?* must provide value
Yes No
Please upload your guidance here.
Have you been laboratory tested for COVID-19? * must provide value
Yes No
Are you scheduled to be tested for COVID-19?* must provide value
Yes No
When is your appointment?* must provide value
Today M-D-Y
What date were you tested?* must provide value
Today M-D-Y
Were the results of your laboratory test positive (+) for COVID-19 or negative (-) for COVID-19?* must provide value
Positive (+)
Negative (-)
Results Pending
Positive (+)
Negative (-)
Results Pending
If you have documentation of your results, please upload it here.
Please describe the type of test. * must provide value
For Example: Swab, Blood Test, etc.
Where were you tested? * must provide value
Would you like to schedule an appointment to be tested for COVID-19 by Employee Health?* must provide value
Yes No
Are you a patient facing employee? * must provide value
Yes No
Have you been in contact with someone diagnosed with COVID-19 (laboratory confirmed)?* must provide value
Yes
No
I Don't Know
What was the reason for your potential exposure? Please select all that apply. * must provide value
Community
Travel
Direct Patient Care
Healthcare Facility (Hospital, Urgent Care, Primary Care, Nursing Home, etc.)
Other
Community
Travel
Direct Patient Care
Healthcare Facility (Hospital, Urgent Care, Primary Care, Nursing Home, etc.)
Other
Other. Please Specify:* must provide value
Please provide additional details as to where the exposure occurred. Please be specific (for example: Home, Family Member, Emergency Department, Patient Room, Waiting Room, etc.)* must provide value
Estimated Exposure Date* must provide value
Today M-D-Y
Did you care for this patient at Children's? * must provide value
Yes No
What was your last date worked? * must provide value
Today M-D-Y
What was the last shift you worked? * must provide value
What is your next scheduled day of work?* must provide value
Today M-D-Y
What type of PPE do you wear while at work as part of the Universal Masking Guidelines? Check all that apply.* must provide value
Procedure
N95
Cloth
Other
Other. Please Specify: * must provide value
Premise Exposure Dates Notes
Patient Interaction While providing care, were you within 6 feet of the patient for more than 10 minutes? * must provide value
Yes
No
I don't know
Approximately how many shifts or encounters did you have with this patient? * must provide value
Describe your interaction. Please be specific. * must provide value
Did you complete any procedures considered to be aerosol generating?* must provide value
Yes
No
I don't know
Premise Patient Interaction Notes
Were you wearing Personal Protective Equipment (PPE)?* must provide value
Yes No
While providing care, was there a breach of isolation precautions (PPE)? * must provide value
Yes No
Please provide additional details. * must provide value
What type of mask?* must provide value
Respirator (N95, PAPR)
Facemask
Cloth Mask
Other
Respirator (N95, PAPR)
Facemask
Cloth Mask
Other
What other type of mask? * must provide value
Patient MRN
Review of Symptoms Have you experienced any of the following symptoms in the past 14 days?
Are you experiencing symptoms of any illness at this time?* must provide value
Yes No
Please list any additional symptoms you are experiencing or important information we should know about the symptoms reported above.
Are any of the above symptoms related to seasonal allergies? * must provide value
Yes No
Please elaborate. Which symptoms are caused by seasonal allergies? * must provide value
Are you currently taking any medications to treat these symptoms? * must provide value
Yes No
What was the approximate date you began experiencing any of the above symptoms? * must provide value
Today M-D-Y
Please list the medications you are taking.* must provide value
Were you working 48 hours prior to symptom onset? * must provide value
Yes No
Did you provide patient care within these 48 hours? * must provide value
Yes
No
I Don't Know
Please include as much information about the patient care you provided as possible. * must provide value
Were you within 6 feet of any co-workers for longer than 15 minutes without PPE?* must provide value
Yes
No
I Don't Know
Please list the names of these coworkers. * must provide value
Premise Symptom Notes
Have you called out of work for being sick?* must provide value
Yes No
Premise Community Exposure Notes
2020 Travel Information Have you traveled outside of Georgia in the past 14 days? * must provide value
Yes No
Date Returned to Georgia* must provide value
Today M-D-Y
Have you traveled internationally or domestically? Select all that apply. * must provide value
International (Outside the United States)
Domestic (Within the United States)
International (Outside the United States)
Domestic (Within the United States)
Please list all domestic travel (within the United States). Be specific, include dates, and purpose. * must provide value
Please list all international travel (outside the United States). Be specific, include dates, and purpose. * must provide value
What was the reason of this travel? Select all that apply. * must provide value
Personal
To Work at Another Healthcare Facility
Other
Personal
To Work at Another Healthcare Facility
Other
Date of last shift at other Healthcare Facility. * must provide value
Today M-D-Y
Other. Please specify. * must provide value
Premise Travel Notes
Premise PPE Notes
Have you completed another Risk Assessment prior to this one?* must provide value
Yes No
I confirm that the information provided in this form has been completed to the best of my ability. I acknowledge that the purpose of this information is for risk assessment only and does not constitute a confirmation of an exposure.* must provide value
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