This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

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.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

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}$/

/^(?:$?([2-9]0[1-9]|[2-9]1[02-9]|[2-9][2-9][0-9]|800|811)$?)\s*(?:[.-]\s*)?([0-9]{3})\s*(?:[.-]\s*)?([0-9]{4})(?:\s*(?:#|x\.?|ext\.?|extension)\s*(\d+))?$/

/^((((\+44|0044)\s?\d{4}|$?0\d{4}$?)\s?\d{3}\s?\d{3})|(((\+44|0044)\s?\d{3}|$?0\d{3}$?)\s?\d{3}\s?\d{4})|(((\+44|0044)\s?\d{2}|$?0\d{2}$?)\s?\d{4}\s?\d{4}))(\s?\#(\d{4}|\d{3}))?$/

/^\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}$/

/^(\d|[01]\d|(2[0-3]))(:[0-5]\d){2}$/

/^([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})?$/

YfwRVJyXNebDxU5NkWqpBv5dMmEuh4RsioDyDt8rqW2HGFLLhoNHb2rgUQ5q5GmqQqWczsQ3uR8t8SJeabuiBQrG6iJwe2kTrukpb3JKWpsmPamd6kLUsFExeIp

Employee Exposure Survey

Automatic Date Field

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

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

M-D-Y

Phone number
Número de teléfono

* must provide value

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

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

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

Employee Exposure Survey

You will be asked to enter your email twice below. It is critical that we have your correct preferred email address to contact you.

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

You have selected an option that triggers this survey to end right now.