The code block below illustrates how one might use # and // as comments in your logic and calculations.

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Required format:

OHS Returning Traveler Activity Survey

Please complete the survey below related to your recent travel activity.

All employees of Partners and its member institutions who travel to countries of interest must contact Occupational Health Services (OHS) before returning to work. Locations of interest currently include China (including Hong Kong and Macau), South Korea, Italy, Iran, Japan, and Europe.

Partners Employees will be furloughed from work upon their return date for 14 days.

Massachusetts General Hospital Occupational Health Services (MGH OHS) will be serving as the central point of contact for all Partners travelers to 2019-nCoV affected areas, regardless of hospital affiliation. Before returning to work, complete the Returning Employee Travel Activity Survey. This survey will be reviewed by MGH OHS.

If you have any questions, contact MGH OHS at 617-726-2217 during normal business hours (Monday-Friday from 7a-5p). If MGH OHS is closed, please call 617-726-2000 and ask the operator to page the MGH OHS on-call clinician (pager #21272).

Thank you.

First Name

* must provide value

Last Name

* must provide value

Employee ID number (you can find this on the back of your ID badge, or ask your manager)

Date of Birth

* must provide value

D-M-Y

What is your employee status?

* must provide value

Manager Name

Manager Email

Facility at Partners

* must provide value

If other facility, specify which facility

Best phone number to reach you

* must provide value

Best email address to email you

* must provide value

Which countries did you travel to?

* must provide value

China

South Korea

Italy

Iran

Japan

Europe

Where did you travel in China?

* must provide value

Wuhan

Other

List the cities you visited within the countries of interest

Expand

When did you arrive to any of the countries of interest?

* must provide value

D-M-Y

When did you depart from any of the countries of interest?

* must provide value

D-M-Y

When did you arrive in the US?

D-M-Y

Did you have any contact with the following during your travel?

* must provide value

Individuals who were suspect or confirmed for 2019-nCoV

other sick contacts

health care facilities

I did not have any contact with the above

Do you have any current symptoms?

* must provide value

Cough or shortness of breath

Nausea, vomiting, or diarrhea

Fever or feeling feverish

I do not have any of the above symptoms

ATTENTION!
Because you have reported a fever or symptoms, further evaluation is required.

Any employee who experiences symptoms of the coronavirus should remain at home and contact MGH OHS at 617-726-2217 during normal business hours (Monday-Friday from 7a-5p). When MGH OHS is closed, please call 617-726-2000 and ask the page operator to page the MGH OHS on-call clinician (pager #21272) to report symptoms. MGH OHS will then guide you on next steps.

DO NOT REPORT TO WORK until you have been cleared to do so by OHS.

If you are already at work, put on a face mask, tell your supervisor you are ill, isolate yourself in a room and contact OHS at the numbers above.

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.