Yes
No
If you are experiencing new onset or worsening symptoms and feel you may need COVID-19 testing, please fill out the form below.
Please do not fill out this form if you have already received a COVID-19 positive result in the past 10 days. If you have a positive test, of any kind, please fill out the test reporting form: https://redcap.link/CCC.covid.test.report
TO REPORT AN EXPOSURE TO A COVID + PERSON AND YOU ARE ASYMPTOMATIC (for UNM Health System employees only): If you have had an exposure to COVID-19 (regardless of location) OR have a recent travel history and are currently asymptomatic, please fill out the exposure survey which will then email you the required 14-Day Symptom Survey at: https://redcap.link/unmh.COVID.symptom.survey
TO REPORT A TEST RESULT: If the COVID Call Center has sent you for testing at the UNMH Ambulatory COVID Screening Clinic (ACSC), or have obtained a positive result elsewhere and need to report your test results, please do that here: https://redcap.link/CCC.covid.test.report
Test results can be obtained through the UNM Health System Patient Portal.
Today's Date
* must provide value
Now M-D-Y H:M
First Name
* must provide value
Last Name
* must provide value
Date of Birth
* must provide value
Today M-D-Y
Enter your work email:
Note: UNMH, UNMMG, SRMC and UNM emails
end in "@salud.unm.edu" "@unmmg.org"
"@srmc.unm.edu" and "@unm.edu"
* must provide value
Re-enter your work email:
Note: UNMH, UNMMG, SRMC and UNM emails
end in "@salud.unm.edu" "@unmmg.org"
"@srmc.unm.edu" and "@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.
Do you prefer to use your work email or personal email to receive information on test scheduling?
Work Email
Personal Email
What is your personal email?
Please confirm your personal email.
You will see this message until your email addresses match.
Please make sure you have entered your correct email address twice.
Your Medical Record Number (MRN) if known
When is your next scheduled shift?
Today
Tomorrow
3 days or more
I work from home
Do you work in a clinical setting?
Yes
No
When was your last day on campus, either at work or for another reason?
* must provide value
Today M-D-Y
Supervisor's name
* must provide value
Supervisor's phone number
Name of your Department
* must provide value
If you work in a clinical area
Your personal and preferred phone number
Employer
* must provide value
UNMH (UNM Hospital)
UNMMG (UNM Medical Group)
SRMC (Sandoval Regional Medical Center)
UNMHSC (UNM Health Sciences Center which includes all Faculty, Fellows, Residents, Staff, HSC Students)
UNM (Staff and Faculty on Main Campus or Branch Campuses)
Other
Company or employers name
Mark all that apply
* must provide value
UNMH
UNMMG
UNMHSC
SRMC
FACULTY
FELLOW OR RESIDENT
STAFF
CONTRACTED TRAVELER
LOCUMS TENENS PROVIDER
VENDOR
UNM MAIN CAMPUS
UNM BRANCH CAMPUS
UNM CHILDREN'S CAMPUS
UNM SHAC
STUDENT, HSC
STUDENT, UNM MAIN OR BRANCH CAMPUS
STUDENT, OTHER
OTHER
Name of the organization you are a student at
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I am reporting
* must provide value
This is my first time reporting symptoms for my current illness.
I have already reported symptoms and need to report either worsening or additional symptoms.
Other symptoms not listed above
Enter the date and time you started to experience your first symptom.
* must provide value
Now M-D-Y H:M
Hours since symptom onset
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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 type of COVID-19 vaccine (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
Received Pfizer
Received Moderna
Received J&J
Received other type of COVID vaccine
I have not received a COVID-19 booster shot
Other COVID Vaccine Received- Please name the other type and number of doses received of any COVID vaccine that you received
Have you had COVID-19 in the past three months?
Yes
No
Date of recent COVID positive result in the past 3 months
Today M-D-Y
Have you had an exposure to a known or presumed positive COVID-19 infected person in the past 14 days?
* must provide value
No, I do not know of any recent exposures
Yes, a work-related exposure
Yes, a community or household exposure
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Your proposed Test Date is:
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You MUST click submit at the bottom of this page to complete this form.
Dear ______ ,
We are sorry to hear you are experiencing symptoms. Based on your input, please begin to quarantine while we work to schedule COVID-19 testing for you.
You will be contacted by the Covid Call Center at your work email with your test date and instructions on scheduling.
Testing Location
DO NOT SHOW UP WITHOUT SCHEDULING AN APPOINTMENT FIRST
UNMH Ambulatory COVID Screening Clinic (ACSC) 1131 University Blvd. NE 87102 Suite K Albuquerque, NM 87102 You may experience some delay at the testing site depending on testing volumes.
Removal from Work
In addition, an email notification will be sent to you and your supervisor removing you from work.
How to Get Your Test Results
Once testing is complete, you may find your test results on the patient portal at: https://unmhealth.org/patients-visitors/myhealth.html
If you have not signed up for the patient portal, you may do so at the time of your appointment registration by logging into the link above with your email and password during the appointment registration.
Reporting Results
Negative Results
If results are NEGATIVE, AND you have been without fever or chills and not taken fever-reducing medications for 24 hours OR you have not had any vomiting or diarrhea in the past 48 hours, please report your test results here: https:redcap.link/CCC.covid.test.report and follow the instructions on the survey. If you have had these symptoms, please call the COVID Call Center at (505) 515-8212 for further instruction.
Positive or Inconclusive Results
Report positive or inconclusive results at h tt ps:redcap.link/CCC.covid.test.report where you will receive additional instruction.
Main, Branch, and HSC non-clinical employees are also required to report their positive test results to UNM via https://hr.unm.edu/self-report
When to Seek Emergency Care
If you are experiencing any of the following symptoms, please seek emergent care at an emergency room or by calling 911
Trouble breathing Persistent pain or pressure in the chest New confusion Inability to wake or stay awake Pale, gray, or blue-colored skin, lips, or nail beds, depending on skin tone This list is not all possible symptoms. Please call your medical provider or the COVID Call Center for any other symptoms that are severe or concerning to you.
Dear ______ ,
We are sorry to hear you are experiencing symptoms. Based on your input, please begin to quarantine while we work to schedule COVID-19 testing for you.
You will be contacted by the Covid Call Center at your work email with your test date and instructions on scheduling.
Testing Location
DO NOT SHOW UP WITHOUT SCHEDULING AN APPOINTMENT FIRST
UNMH Ambulatory COVID Screening Clinic (ACSC) 1131 University Blvd. NE 87102 Suite K Albuquerque, NM 87102 You may experience some delay at the testing site depending on testing volumes.
Removal from Work
In addition, an email notification will be sent to you and your supervisor removing you from work.
How to Get Your Test Results
Once testing is complete, you may find your test results on the patient portal at: https://unmhealth.org/patients-visitors/myhealth.html
If you have not signed up for the patient portal, you may do so at the time of your appointment registration by logging into the link above with your email and password during the appointment registration.
Reporting Results
Negative Results
If results are NEGATIVE, AND you have been without fever or chills and not taken fever-reducing medications for 24 hours OR you have not had any vomiting or diarrhea in the past 48 hours, please report your test results here: https:redcap.link/CCC.covid.test.report and follow the instructions on the survey. If you have had these symptoms, please call the COVID Call Center at (505) 515-8212 for further instruction.
Positive or Inconclusive Results
Report positive or inconclusive results at https:redcap.link/CCC.covid.test.report where you will receive additional instruction.
Main, Branch, and HSC non-clinical employees are also required to report their positive test results to UNM via https://hr.unm.edu/self-report
When to Seek Emergency Care
If you are experiencing any of the following symptoms, please seek emergent care at an emergency room or by calling 911
Trouble breathing Persistent pain or pressure in the chest New confusion Inability to wake or stay awake Pale, gray, or blue-colored skin, lips, or nail beds, depending on skin tone This list is not all possible symptoms. Please call your medical provider or the COVID Call Center for any other symptoms that are severe or concerning to you.
Dear ______ ,
We are sorry to hear you are experiencing a symptom. Based on your response of reporting only one symptom of concern, you may continue to work, but will also be sent for testing. HOWEVER, if you begin to experience additional symptoms or a worsening of symptoms, please fill out this form again for reassessment.
You will be contacted by the Covid Call Center at your work email with your test date and instructions on scheduling.
Testing Location
DO NOT SHOW UP WITHOUT SCHEDULING AN APPOINTMENT FIRST
UNMH Ambulatory COVID Screening Clinic (ACSC) 1131 University Blvd. NE 87102 Suite K Albuquerque, NM 87102 You may experience some delay at the testing site depending on testing volumes.
Supervisor Notification
In addition, an email notification will be sent to you and your supervisor stating you may continue to work.
How to Get Your Test Results
Once testing is complete, you may find your test results on the patient portal at: https://unmhealth.org/patients-visitors/myhealth.html
If you have not signed up for the patient portal, you may do so at the time of your appointment registration by logging into the link above with your email and password during the appointment registration.
Reporting Results
Negative Results
If results are NEGATIVE, AND you have been without fever or chills and not taken fever-reducing medications for 24 hours OR you have not had any vomiting or diarrhea in the past 48 hours, please report your test results here: https:redcap.link/CCC.covid.test.report and follow the instructions on the survey. If you have had these symptoms, please call the COVID Call Center at (505) 515-8212 for further instruction.
Positive or Inconclusive Results
Report positive or inconclusive results at https:redcap.link/CCC.covid.test.report where you will received additional instruction.
Main, Branch, and HSC non-clinical employees are also required to report their positive test results to UNM via https://hr.unm.edu/self-report
When to Seek Emergency Care
If you are experiencing any of the following symptoms, please seek emergent care at an emergency room or by calling 911
Trouble breathing Persistent pain or pressure in the chest New confusion Inability to wake or stay awake Pale, gray, or blue-colored skin, lips, or nail beds, depending on skin tone This list is not all possible symptoms. Please call your medical provider or the COVID Call Center for any other symptoms that are severe or concerning to you.
Dear ______ ,
We are sorry to hear you are experiencing a symptom. Based on your response of reporting no symptoms or only one of the minor types of COVID-19 related symptoms, you may continue to work and do not need to test at this time. HOWEVER, if you begin to experience additional symptoms or a worsening of symptoms, please fill out this form again for reassessment.
Supervisor Notification
In addition, an email notification will be sent to you and your supervisor stating you may continue to work.
When to Seek Emergency Care
If you are experiencing any of the following symptoms, please seek emergent care at an emergency room or by calling 911
Trouble breathing Persistent pain or pressure in the chest New confusion Inability to wake or stay awake Pale, gray, or blue-colored skin, lips, or nail beds, depending on skin tone This list is not all possible symptoms. Please call your medical provider or the COVID Call Center for any other symptoms that are severe or concerning to you.
You MUST click submit to complete this form.