COVID-19 Symptoms & Exposure Situations
This form is to be used by staff who have been exposed to COVID-19, or have symptoms of COVID-19 but have not been diagnosed with COVID-19.

This form should be completed by staff assigned to Edison, TSSC, or FSC, Prairie Care.

If you have received a positive COVID-19 test, stop. Instead, complete the Confirmed Positive COVID-19 Form: https://forms.gle/7peMW7Sbc1FvLhFY8

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Email *
COMPLETE THE FIRST THREE QUESTIONS, THEN MOVE ON TO THE REPORTING OPTION THAT BEST DESCRIBES YOUR CURRENT SITUATION.
There are three options to choose from.
1. First and Last Name: *
2. Position *
3. Phone Number *
SITUATION 1:  YOU WERE IN CLOSE CONTACT WITH SOMEONE WHO IS POSITIVE FOR COVID-19.
You must stay home for 14-days and monitor symptoms. Close contact is defined as time with another person within 6 feet for 15 minutes or longer, regardless of wearing masks. Please answer the following questions.
Date you had close contact:
MM
/
DD
/
YYYY
Date you were last at work in a District building:
MM
/
DD
/
YYYY
Which building were you in? Select all that apply. If this does not apply, select N/A.
Which areas of the building did you visit, e.g. classroom 123, gym, lunch room, bathroom on floor 1, etc. If this does not apply, skip this question.
How long were you in that building?
Do you plan or have you been tested? If you choose not to get tested, you must stay home for 14 days per the Minnesota Department of Health decision tree requirements.
Clear selection
If you were tested, what was the date of the test? Skip this question if you were not tested.
MM
/
DD
/
YYYY
What was the result of your test? Skip this question if you were not tested.
NOTE: contact your building coordinator once you have the results. You will follow the MDH decision tree on your return-to-work date. If your test is positive, complete the Confirmed Positive COVID-19 Form: https://forms.gle/7peMW7Sbc1FvLhFY8
Clear selection
SITUATION 2:  You have COVID-19 symptoms.
If you have COVID-19 symptoms and you choose NOT to be tested, you must remain home 10 days since symptoms first appeared AND until no fever for at least 24 hours without medication AND improvement of other symptoms. If you tested negative or received an alternative diagnosis you can return to work 24 hours after symptoms have improved.
Please indicate if you have experienced any of the following symptoms. COVID-19 symptoms typically included at least one of the more common symptoms or two or more of the less common symptoms. Check all that apply.
Date symptoms began:
MM
/
DD
/
YYYY
Do you plan to be or have you been tested?
If you choose not to get tested, you must stay home for 10 days since symptoms first appeared AND until no fever for at least 24 hours without medication per the Minnesota Department of Health decision tree requirements.
Clear selection
Date of COVID-19 test:
Skip this question if you were not tested.
MM
/
DD
/
YYYY
What was the result of your test?
If you did not get tested, skip this question. NOTE: contact your building coordinator once you have the results. You will follow the MDH decision tree on your return-to-work date. If your test is positive, complete the Confirmed Positive COVID-19 Form: https://forms.gle/7peMW7Sbc1FvLhFY8
Clear selection
Did you see a medical practitioner? If yes, was there any other diagnosis?
Clear selection
When were you last at work in a District building?
MM
/
DD
/
YYYY
Which building were you in? Select all that apply. If this does not apply, select N/A.
Which areas of the building did you visit, e.g. classroom 123, gym, lunch room, bathroom on floor 1, etc. If this does not apply, skip this question.
How long were you in that building? If this does not apply, skip this question.
Note: If your symptoms are not improving, please contact your health care provider for further guidance and/or additional testing.
SITUATION 3: You live with someone who has COVID-19 symptoms.
In this situation, if your household member chooses NOT to be tested, you must stay home and quarantine for at least 14 days. If your household member is tested, but receives a negative result, you can return to work.
Please indicate which of the following symptoms are being experienced by the person you live with. COVID-19 symptoms typically included at least one of the more common symptoms or two or more of the less common symptoms. Check all that apply.
Does the person you live with plan on being or has been tested?
If they choose not to get tested, you must stay home for at least 14 days per the Minnesota Department of Health decision tree requirements.
Clear selection
What is the date they were tested?
If they were not tested, skip this question.
MM
/
DD
/
YYYY
What wast he result of the test?
If they did not test, skip this question. NOTE: contact your building coordinator once you have the results. You will follow the MDH decision tree on your return-to-work date. If your test is positive, complete the Confirmed Positive COVID-19 Form: https://forms.gle/7peMW7Sbc1FvLhFY8
Clear selection
Date quarantined started:
MM
/
DD
/
YYYY
When were you last at work in a District building:
MM
/
DD
/
YYYY
Which building were you in? Select all that apply. If this does not apply, select N/A.
Which areas of the building did you visit, e.g. classroom 123, gym, lunch room, bathroom on floor 1, etc. If this does not apply, skip this question.
How long were you in that building? If this does not apply, skip this question.
A copy of your responses will be emailed to the address you provided.
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