COVID-19/Coronavirus Employee Incident Reporting Form

Background Information

The background section is Required Information

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Your full name:

Your position/title:

Your phone number:

Your email address:

Email address must be of a valid format.

Nature of this report(Required):

This field is required.

Date of incident(Required):

This field is required.

Primary Campus Location(Required):

This field is required.

Location/Campus/Bldg/Office #:

Close Contact-COVID-19 Contact Tracing

Were you physically on any Webster campus during your contagious period? (The contagious period begins 2 days before you developed symptoms) If yes, or you are not sure please provide details of anyone you may of had a "close contact" which is someone who you have been within 6 feet distance for more than 15 minutes or more during a 24 hour period.

Name or Location

Select a Role

Employee ID Number

Phone number

Email address

Questions

Provide a general overview of why you are submitting this report.(Required) This field is required.

Did you take a COVID-19 Test?(Required) This field is required.

Where were you tested for COVID-19? This field is required.

Date of Test for COVID-19? This field is required.

When was the last date you reported to campus?(Required) This field is required.

Date of your test outcome for COVID-19?(Required) This field is required.

What was the results of your COVID-19 test?(Required) This field is required.

Are you experiencing any COVID-19 like symptoms? (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 or Diarrhea)(Required) This field is required.

Date your COVID-19 like symptoms appeared?(Required) This field is required.

Have you been instructed to quarantine following possible exposure to COVID-19? (This is different from isolation. Isolation is for those who are sick, and quarantine is for those who are currently well but have been exposed to the virus.)(Required) This field is required.

Who instructed you to quarantine?(Required) This field is required.

Are you considered fully vaccinated against COVID-19?(Required) This field is required.

If you are not vaccinated against COVID-19 do you have an approved exemption on file with HR? If No, please reach out to HR immediately to complete and exemption form and meeting. All exemptions are due 15 days after hire. This field is required.

If you are fully vaccinated against COVID-19/Coronavirus, please indicate which vaccine you were given? In general, people are considered fully vaccinated: 2 weeks after their second dose in a 2-dose series, such as the Pfizer or Moderna vaccines, or 2 weeks after a single-dose vaccine, such as Johnson & Johnson’s Janssen vaccine If you don’t meet these requirements, regardless of your age, you are NOT fully vaccinated. Keep taking all precautions until you are fully vaccinated. according to CDC guidelines:

Moderna (2 shots) Pfizer (2 shots) Johnson & Johnson (1 shot)

You must make at least one selection.

Have you received a booster shot for COVID-19?(Required)

Yes No

You must make at least one selection.

Did you administer a COVID-19 self-tests? If your COVID-19 test was self administered if you received a positive result, stay home and call your healthcare provider/Department Health (DHSS) for a testing site to administer a test to supply Webster with written proof of diagnosis. Testing Site Website: https://health.mo.gov/living/healthcondiseases/communicable/novel-coronavirus/community-test.php(Required)

Yes No

You must make at least one selection.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Background Information

Close Contact-COVID-19 Contact Tracing

Questions

Supporting Documentation

Submission