PMG COVID-19 Symptom Reporting Form

PMG COVID-19 Symptom Reporting Form
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Best Number to reach you *
Please enter a valid phone number.
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you experiencing any of the symptoms listed that may be COVID-19 Related? (Select all that apply)*

Fever or chillsShortness of breath or difficulty breathingCoughFatigueSore throatNausea or vomitingNew loss of taste or smellDiarrheaCongestion or runny nose
Do you recall being exposed to someone who tested positive for COVID-19 within the last 10 days?*

At homeAt workAt a public indoor locationAt a public outdoor locationUnknown
When is your most recent contact with a coworker who tested positive for COVID-19?*

MonthDayYear
Date
Were you wearing Personal Protective Equipment when you were exposed?*

YesNo
What personal protective equipment were you Wearing? (Select all items you were wearing)

Medical Grade surgical mask supplied by PMGSurgical maskCloth maskN95 respirator supplied by PMGKN 95 supplied by PMGN95 respiratorKn95 maskI was not wearing any Type of PPE
List all Co-workers you have come in contact with at work within the last 3 days (Separate names with a comma) *
have you been tested for COVID-19 as a result of exposure or after developing symptoms?*

YesNo
When did you take the test?

MonthDayYear
Date
Please upload your completed test if you have one to this form. This can be a picture of your test or an online document.

Cancelof
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