NorthShore COVID-19
Employee Screening Questionnaire

Please be advised that Legacy NS and NCH employees are no longer required to complete daily screening.

If you have questions, please contact Employee Health (Legacy NorthShore) or Occupational Health (NCH).

If you are experiencing COVID-19 symptoms...
NorthShore (Legacy and Swedish) Employees: Please call your Manager/Supervisor immediately to notify them of your absence, and complete this survey...
NorthShore EH Questionnaire Link

Northwest Community Healthcare Employees: Please call your Manager/Supervisor immediately to notify them. Your Manager/Supervisor will alert OEHS and the standard process will be followed.

Schedule or walk into a clinic near you to get a booster today.

Only NCH team members are required to complete survey.
NCH Employee ID
(or enter "000000" if you do not have an Employee ID)
* must provide value

Last Name
* must provide value

Have you...

Had any new symptoms of COVID-19 (Fever, chills, cough, shortness of breath, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion, runny nose, nausea, vomiting, diarrhea),
Traveled internationally in the last 14 days.
Had an exposure to a CONFIRMED positive Covid-19 person within the last 14 days?
- Exposure = Within 6 feet for longer than 15 mins AND not wearing appropriate PPE.
- Appropriate PPE = MASK in community/home/coworker OR MASK and EYE PROTECTION for patient care.

* must provide value

Yes No

Are you partially vaccinated and reporting symptoms or exposure?

* must provide value

Yes No

Are you WITHOUT symptoms AND reporting...

International travel?

* must provide value

Yes No

If you travelled internationally, are you FULLY vaccinated (Received both doses of Pfizer/Moderna OR one dose of Johnson & Johnson/Janssen AT LEAST 15 days ago)
* must provide value

Yes No

Have you travelled internationally AND followed EHS return to work instructions?
* must provide value

Yes No

Are you reporting an exposure but NO symptoms?
* must provide value

Yes No

If you are reporting confirmed exposure, are you fully vaccinated (Received both doses of Pfizer/Moderna OR one dose of Johnson & Johnson/Janssen AT LEAST 15 days ago)?
* must provide value

Yes No

Please provide your phone number for Employee Health Services (EHS) to reach out to you to schedule future COVID test.
* must provide value

Are you reporting any new symptoms of COVID-19 (Fever, chills, cough, shortness of breath, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion, runny nose, nausea, vomiting, diarrhea) AND exposure?
* must provide value

Yes No

Are you reporting COVID-19 symptoms but NO exposure?

* must provide value

Yes No

Have you been diagnosed with COVID-19 in the last 14 days?
* must provide value

Yes No

Did you follow Employee Health Return To Work instructions?

* must provide value

Yes No

Have you received a COVID vaccine in the last 72 hours AND are experiencing fatigue, chills, muscle aches, headache, and nausea for less than 48 hours?
* must provide value

Yes No

Have you had exposure?
* must provide value

Yes No

Have you traveled to a high risk state* in the last 14 days?

*Alabama, Alaska, Arizona, Arkansas, Colorado, Connecticut, Delaware, Florida, Georgia, Hawaii, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, Wyoming, District of Columbia, Guam, and the Virgin Islands.

- Unless your primary residence is in this state.
View High Risk States
* must provide value

Yes No

Are you FULLY vaccinated AND NOT severely immunocompromised?

(currently on chemotherapy, received organ transplant, HIV/AIDs with CD4 count <200, Combined primary immunodeficiency disorder, taking > 20 mg prednisone or other immunosuppressive medication)

* must provide value

Yes No

Do you meet exemption (listed below)?

You have previously tested positive for COVID-19 and recovered in the past 90 days and have no symptoms
Pre-arrival negative PCR test result < 72 hours prior to arrival in IL
Airport layover, changing planes in a high incidence state
Driving through a high incidence state(s)
Travel to bring child to college
Travel for medical care
Travel for shared parental custody
Travel for work purposes if you are an ‘essential worker’

Travel FAQ 9/1/2020
Please Note: Amount of time spent in a high risk state as your final destination is not considered an exemption; travel quarantine applies regardless of the amount of time spent in the high risk state unless you meet one of the following exemptions...

* must provide value

Yes No

NorthShore COVID-19
Employee Screening Questionnaire

Date:
Time:
<<- Go Back and Review Screening Questions

PLEASE DO NOT CLOSE THIS BROWSER WINDOW UNTIL YOU HAVE DISPLAYED IT TO THE SCREENER

KEY SAFETY PRACTICES

* Receive the COVID-19 booster *
* Keep 6 ft distance from everyone whenever possible *
* Perform hand hygiene *
* When interacting with COVID-19 patients please wear a N95 facemask (if boosted can double mask) and a gown. *
* In clinical areas always wear a N95 facemask. In non-clinical areas wear a N95 facemask as directed. *
* Masks should completely cover the nose and mouth and fit snugly against the sides of face without gaps *
* Participate in symptom and temperature screening and stay home if you are sick *

NorthShore COVID-19 Employee Screening Questionnaire

NorthShore COVID-19 Employee Screening Questionnaire

NorthShore COVID-19 Employee Screening Questionnaire

NorthShore COVID-19
Employee Screening Questionnaire

NorthShore COVID-19
Employee Screening Questionnaire

NorthShore COVID-19
Employee Screening Questionnaire