View equation
Fill out this form if you have had an exposure to a COVID-19 positive person or have recently traveled and would like help monitoring for symptoms. After you click submit, you will be emailed a 10-day symptom survey.
If you test positive for COVID-19 during this survey, you may stop the survey, although it will still be emailed for a total of 10 days. Please report your positive result here: https://redcap.link/UNM.CCC.SurveySelector
If you already have symptoms and need to be sent for testing, visit this link: https://redcap.link/UNM.CCC.SurveySelector
Employee Name (First and Last Name)Nombre del empleado (nombre y apellido)
* must provide value
full name (nombre completo)
First Name
* must provide value
Last Name
* must provide value
Your Birth date (NOT the patient's)Su fecha de nacimiento (NO la del paciente)
* must provide value
Today M-D-Y
Phone numberNúmero de teléfono
* must provide value
your personal contact number (su número de contacto personal)
You will be asked to enter your email twice below. It is critical that we have your correct preferred email address to contact you.
Enter your preferred email: Note: HSC emails end in "@salud.unm.edu"
Escriba su correo electronico de HSC o su correo electronico alternativo preferido:
Nota: Los correos electronicos de HSC terminan en "@salud.unm.edu "
* must provide value
Your email address (su correo electronico)
RE-Enter your preferred email: Note: HSC emails end in "@salud.unm.edu"
Escriba su correo electronico de HSC o su correo electronico alternativo preferido:
Nota: Los correos electronicos de HSC terminan en "@salud.unm.edu "
* must provide value
Your email address (su correo electronico)
You will see this message until your email addresses match.
Please make sure you have entered your correct email address twice.
Verá este mensaje hasta que sus direcciones de correo electrónico coincidan.
Asegúrese de haber ingresado su dirección de correo electrónico correcta dos veces.
Which Entity are you primarily associated with?
* must provide value
Students (School of Medicine and HSC colleges)Estudiantes (Escuela de medicina y colegios del Centro de Ciencias de la Salud)
Students (all others) Estudiantes (todos los demás)
Physician Residents and Fellows Médicos Residentes y Becados
UNM (faculty or staff) UNM (facultad)
UNMH (APPs, EVS, Nurses, etc.) Hospital UNM (Proveedores de practica avanzada, personal de limpieza, enfermeros, etc.)
UNMMG
SRMC
Vendors and outside contractors Comerciantes y contratistas externos
Other Otro
What other entity are you associated with?
COVID-19 Vaccination Status - Please select the option which identifies your initial vaccine status
* must provide value
Not vaccinated
Fully Vaccinated with Johnson and Johnson
Fully Vaccinated (Second shot) Moderna
Fully Vaccinated (Second shot) Pfizer
Partially Vaccinated (First shot) Moderna
Partially Vaccinated (First shot) Pfizer
Other vaccine type, not your booster shot
Other COVID Vaccine Received- Please name the other type and number of doses received of any COVID vaccine that you received
Latest Date of Vaccine Administration - Please let us know when the latest date that you received a COVID vaccine shot
* must provide value
Today M-D-Y
Pfizer
Moderna
J&J
Other vaccine type
I have not received a COVID-19 booster shot
Date when COVID-19 Booster Shot was received
* must provide value
Today M-D-Y
Have you had COVID-19 in the past three months?
Yes
No
Date of Recent COVID Infection
Today M-D-Y
I want to report (select one)Quiero reportar (marque uno)
* must provide value
A shift in a high risk area (e.g. MEC, ED DECON, ACSC, etc.)Un turno en un área de alto riesgo (ej. MEC, ED DECON, ACSC, etc.)
Exposure to a confirmed COVID-19 case that occurred at work or a breach in PPEEstuvo expuesto a un posible caso o un caso confirmado de COVID-19
Exposure to a symptomatic or confirmed COVID-19 case that occurred in the community
I was notified by my supervisor of a potential exposure, but was not in contact with the patient or staff that was identified.
Recent Travel (within the last 14 days)Viaje reciente (dentro de los últimos 14 días)
Time of exposure (hit the NOW button if this just happened)Hora en la que fue expuesto (presione el boton AHORA si acaba de suceder)
* must provide value
Now M-D-Y H:M time (hora)
Where was this shift? ¿Dónde fue este turno?
CRCC (Critical Respiratory Care Center)CRCC (Centro de cuidados respiratorios críticos)
RACC (Respiratory Acute Care Center)RACC (Centro de cuidados respiratorios críticos)
RICC (Respiratory Intermediate Care Center)RICC (Centro de cuidados respiratorios intermedios)
ED Annex, or other UNMH Testing Site
ICUUnidad de cuidados intensivos
Hospital Ward (designated for COVID-19 patients)Unidad del hospital (designada para pacientes de COVID-19)
SRMC - respiratory unit
OtherOtra
Specify other high risk area:Especificar otra
Today M-D-Y
What kind of shift was this (best approximation)? ¿Qué tipo de turno era (mejor aproximación)?
day (approx 8a-4p) Día (aproximadamente 8am a 4pm)
swing (appox 4p-Midnight) Tarde (aproximadamente 4pm a medianoche)
night (approx Midnight- 8a) Noche (aproximadamente medianoche a 8am)
Work Location for this exposureLugar de trabajo para esta exposicion
ED Annex, or other UNMH Testing Site
UNMH ED Departamento de emergencias de UNMH
UNMH Clinic Clínica de UNMH
UNMH Inpatient Unidad de paciente interno en UNMH
SRMC ED Departamento de emergencias de SRMC
SRMC Clinic Clínica de SRMC
SRMC Inpatient Unidad de paciente interno en SRMC
UNMH offsite buildings that are non-clinical
HSC - non clinical
UNM Main Campus
Other Otro
site of exposure
Other institutionOtra institucion
other place of exposure (otro lugar donde fue expuesto)
Other student associationOtra asociacion de estudiantes
Vendors / Contractors - what entity are you associated with?Comerciantes / Contratistas -
Please enter the staff name if this exposure is to a staff member, otherwise if this is a patient related exposure, please input patient MRN (if known) twice to ensure that it is correct! Por favor ponga el n Enter name of Staff that you were exposed to
Patient MRNNúmero de expediente médico del paciente
MRN if known (número de expediente médico (si lo sabe)
Patient MRN Número de expediente médico del paciente
MRN if known (número de expediente médico (si lo sabe)
You will see this message until the above MRN's match. This is critical for tracking exposures to COVID positive patients!
Continuar
Other patient identifier if MRN not known (ex: put ED Annex if doing a shift in that space)Otro identificador del paciente si el n
Please check boxes of all the PPE you were using during this exposure.Por favor marque todas las casillas del equipo de proteccion personal que pudo usar.
* must provide value
mask - N95 tapaboca- N95
mask - surgical or procedural (blue or yellow)tapaboca- quirurgico o de procedimiento azul o amarillo)
eye protection (TIDI glasses/goggles/other)proteccion para los ojos (gafas TIDI)
eye protection (shield)proteccion para los ojos (escudo)
gownbata
gloves guantes
bouffant (head cover)gorro (protector de la cabeza)
CAPR (controlled air purifying respirator)CAPR (respirador de aire purificado controlado)
PAPR (powered air purifying respirator)PAPR (respirador de aire purificado accionado)
NONENINGUNO
check all used (marque todo lo que uso)
City of exposureCiudad en la que fue expuesto
City (Ciudad)
Country zip code (US)codigo postal (Estados Unidos)
zip code (international)codigo postal (internacional)
start date of travelfecha de inicio del viaje
Today M-D-Y
finish date of travelfecha de finalizacion del viaje
Today M-D-Y
additional sites of travel? Yes
No
City of exposureCiudad en la que fue expuesto
City (Ciudad)
Country zip code (US)codigo postal (Estados Unidos)
zip code (international)codigo postal (internacional)
start date of travelfecha de inicio del viaje
Today M-D-Y
finish date of travel
fecha de finalizacion del viaje
Today M-D-Y
additional sites of travel?
Yes
No
City of exposureCiudad en la que fue expuesto
City (Ciudad)
Country zip code (US)codigo postal (Estados Unidos)
zip code (international)codigo postal (internacional)
start date of travelfecha de inicio del viaje
Today M-D-Y
finish date of travelfecha de finalizacion del viaje
Today M-D-Y
Have you been cleared by the UNM Health System COVID Call Center to return to work?
* must provide value
Yes
No
View equation
Based on the information entered your exposure is not considered to be at risk.
We thank you for taking this survey.
Please fill out this survey again in the future should you believe that you may have had an exposure to COVID.
Based on the information entered your exposure survey is considered to be low risk and you may continue to work if asymptomatic. DO NOT go to work if you have symptoms. Please click submit at the bottom of this page.
You will be emailed a symptom survey and must complete it over the next 14 days after hitting submit. Please continue to work under the following guidance: Comply with strict masking with a procedural mask or higher grade at all times. Eat and drink alone. Maintain a physical distance of 6 feet or more from others as much as possible. Continue to pass through employee screening if at UNM Hospitals or Clinics. Stop working if even mild symptoms develop, notify your supervisor and the UNM Health Systems COVID-19 Call Center at (505) 515-8212, even if vaccinated. 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 If you have any other concerns regarding this exposure, please call the UNM Health COVID Call Center at (505) 515-8212. If you are employed by SRMC, please call 505-994-7442 if you have not already reported this exposure to SRMC Occupational Health. Based on the information entered in your exposure survey you are considered approved to continue to work if asymptomatic. DO NOT go to work if you have symtpoms. Please click submit at the bottom of this page.
You will be emailed a symptom survey and must complete it over the next 10 days after hitting submit. Please continue to work under the following guidance: Comply with strict masking with a procedural mask or higher grade at all times. Eat and drink alone. Maintain a physical distance of 6 feet or more from others as much as possible. Continue to pass through employee screening if at UNM Hospitals or Clinics. Stop working if even mild symptoms develop, and notify your supervisor and the UNM Health Systems COVID-19 Call Center at (505) 515-8212. 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 If you have any other concerns regarding this exposure, please call the UNM Health COVID Call Center at (505) 515-8212. If you are employed by SRMC, please call 505-994-7442 if you have not already reported this exposure to SRMC Occupational Health. Based on the information entered your exposure survey is considered to be a high-risk exposure. Please click submit at the bottom of this page.
Stay home and self-quarantine. You will be emailed a symptoms survey and should complete it over the next 10 days after hitting submit. Notify your supervisor that you are not cleared to work at this time and are waiting to be contacted by the UNM Health Systems COVID Call Center. You will be contacted by the COVID Call Center with further guidance around this exposure. If a work exposure at UNMH, please be sure to have the patient's MRN or name of the person you were exposed to prior to calling. If you do not have this, your supervisor can help you obtain it. If you are not contacted in the next 24 hours, call at (505) 515-8212 If you are employed by SRMC, please call 505-994-7442 if you have not already reported this exposure to SRMC Occupational Health.
Please click submit at the end of this page.
You will be emailed a symptom survey over the next 10 days after hitting submit. Continue working under the following guidance: Comply with strict masking with a procedural mask or higher grade at all times in clinical buildings. Eat and drink alone. Maintain a physical distance of 6 feet or more from others as much as possible. Continue to pass through passive employee screening if at UNM Hospitals or Clinics. If working in a clinical building, stop working if even mild symptoms develop, and notify your supervisor and the UNM Health Systems COVID-19 Call Center at (505) 515-8212. 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 If you have any other concerns regarding this exposure, please call the UNM Health COVID Call Center at (505) 515-8212. If you are employed by SRMC, please call 505-994-7442 if you have not already reported this exposure to SRMC Occupational Health.