Health Management COVID-19 Accommodation Question Title * 1. Full Name Question Title * 2. Today's Date: If you are having symptoms contact your PCP or go to the walk-in clinic for testing. Do NOT wait for PBH Medical Director to send you. You may not return to work without speaking directly to the Medical Director. Your PBH Supervisor needs to complete an HR Accommodation form for your time off due to COVID. Question Title * 3. Phone Number:The Medical Director will review your symptoms within 48 hours. Please enter a good phone number where you can be reached if needed. Question Title * 4. Supervisor's name Question Title * 5. Department Question Title * 6. Have you had any NEW symptoms in the past week?Select all that apply. Don't include symptoms you already had for allergies, COPD, IBS, etc. None Fever Cough Difficulty Breathing Sore Throat Fatigue/Malaise Headache Muscle aches/Pain Nausea/Vomiting Diarrhea Runny Nose/Congestion New Loss of Taste or Smell Other (please specify) Question Title * 7. Within the past 14 days, have you been in close physical contact (6 feet or closer for a least 15 minutes) with a person who is known to have laboratory-confirmed COVID-19 or with anyone who has any symptoms consistent with COVID-19? Yes No Question Title * 8. Are you currently waiting on the results of a COVID-19 test? Yes No Question Title * 9. Have you received the COVID-19 Vaccination? Yes No Question Title * 10. If you received the COVID Vaccination, approximately when did this occur? Done
