COVID-19 Screening and Reporting

COVID-19 Screening and Reporting

 

COVID-19 Screening & Reporting Form
Visitor Information
Travel History
Have you traveled or resided outside of Oklahoma within the last 14 days? *
Event Attendance
Have you attended an event/entertainment venue/gathering or group of greater than 10 people in the last 14 days? The people in your household do not count towards the 10 people. *
Symptom Information
Have you experienced any symptoms within the last 14 days? *
Exposure Information
Have you had direct contact with Confirmed (+) COVID-19 within the last 14 days? *
Have you had direct contact to someone awaiting COVID-19 test results within the last 14 days? *
Do you share a household with anyone who has had symptoms of concern for COVID-19 within the last 14 days? *
Do you share a household with anyone who has been instructed to Self-Isolate within the last 14 days? *
Do you share a household with anyone who has been diagnosed with COVID-19 within the last 30 days? *
Testing Information
Have you tested POSITIVE for COVID-19 within the last 20 days? *
Acknowledgement

The information submitted on this form is complete and accurate to the best of my knowledge.

I acknowledge that this screening tool is being used for clearance to visit Tulsa CARES for the specified reasons and dates stated within this form, based on information I provided. It is not intended for use regarding personal medical evaluation, advice, decisions, and/or treatment. Seek care from your primary care provider or emergency services, as appropriate, for any personal medical needs.

I understand this information is being collected for the purpose of infection prevention and public/employee safety.

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