PMG COVID-19 Symptom Reporting Form
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Best Number to reach you
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you experiencing any of the symptoms listed that may be COVID-19 Related? (Select all that apply)
*
Fever or chills
Shortness of breath or difficulty breathing
Cough
Fatigue
Sore throat
Nausea or vomiting
New loss of taste or smell
Diarrhea
Congestion or runny nose
Do you recall being exposed to someone who tested positive for COVID-19 within the last 10 days?
*
At home
At work
At a public indoor location
At a public outdoor location
Unknown
When is your most recent contact with a coworker who tested positive for COVID-19?
*
-
Month
-
Day
Year
Date
Were you wearing Personal Protective Equipment when you were exposed?
*
Yes
No
What personal protective equipment were you Wearing? (Select all items you were wearing)
Medical Grade surgical mask supplied by PMG
Surgical mask
Cloth mask
N95 respirator supplied by PMG
KN 95 supplied by PMG
N95 respirator
Kn95 mask
I 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?
*
Yes
No
When did you take the test?
-
Month
-
Day
Year
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.
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