Employee Self Asssessment | Upstate HomeCare

With the COVID-19 pandemic, Upstate HomeCare is encouraging all employees, especially employees who have direct patient contact, to self-assess. *All employees are required to self-assess twice per day.* Please use the questions below as a daily self-monitoring reference. If you present any symptoms or answer yes to any of the following, please notify your Branch Manager and fill out the online assessment form.

Date(Required)

Select your branch(Required)

Employee Name(Required)

First Last

Email(Required)

COVID-19 Exposure

Have you knowingly been in close contact with anyone who has tested positive for COVID-19 or who has had symptoms of COVID-19 in the past 14 days?(Required)

Yes

If yes, please let us know the date of exposure. Contact your Branch Manager or Supervisor immediately to determine if you should report to work.

Notify HR to fill out an Employee Exposure Form.

What date were exposed?(Required)

COVID-19 Testing

Have you tested positive for COVID-19 in the past 14 days?(Required)

Yes

If yes, please contact your Branch Manager and Supervisor immediately & stay home.

Notify HR to fill out an Employee Exposure Form.

Fever? If yes, please contact the Branch Manager and Supervisor immediately & stay home.(Required)

Yes

Do you have any of the following respiratory issues, to include: Cough, Sore Throat or Shortness of Breath?(Required)

Yes

If you don’t feel well, please stay home and contact your doctor. If you are out for at least three days, per company policy, you will need a doctor’s note to return to work.

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