Person Submitting Form – Name*Person Submitting Form – Role/TitlePerson Submitting Form – Email*Provider Name*Provider Contact Info – Email*Provider Contact Info – Phone*Operating Group*SelectLocation / Hospital*
Location of incidentService LineSelectWas the provider exposed to Coronavirus through work?*YesNoIf yes, please describe:Is quarantine mandated?*
PUI (Persons Under Investigation)Yes – for 14 day periodYes – while waiting for PUI resultsNoWhich entity mandated quarantine?*
DOH – Department of Health CDC – Centers for Disease Control and PreventionSelectIf quarantined has provider contacted any below?SelectHas the provider been removed from schedule?*YesNoWhen are PUI test results anticipated?
If awaiting PUI results populate this field with date when results will be available. If date unknown leave blank.Quarantine Start Date*Quarantine end date
If awaiting PUI results populate this field with date when results will be available. Envision will follow-up to determine next steps.Anticipated work hours missed due to quarantineWas quarantine secondary to PUI contact?YesNoDid the provider travel from an infected area?YesNoIf yes, which area?Did the provider test positive for Coronavirus?
If the provider was tested for Coronavirus.YesNoIs the provider contractually eligible for PTO?SelectDoes the state provider resides in offer Paid Sick Leave?YesNoIf yes list the state:Work classificationSelectIs the provider able to work from home?SelectDoes the provider have home telemed capabilities?Select