COVID-19 Reporting Form

Directions: Please fill out the form in entirety with all known information.

Please select the category of person you are reporting *

Provider or StaffMember, Guardian or FamilyCardinal Staff

Please check the appropriate box below for who is reporting this information *

Name of Person Reporting Information *

Contact Information for Person Reporting Information *

Provider Reporting Provider/Staff Related Information

Provider Agency Name

Name of Person Suspected or Confirmed

Position/Role of the Person

Date Informed

Date Symptoms of COVID-19 started, if known

YesNo

Does the individual have COVID-19 type Symptoms such as: Cough, Fever, Shortness of breath

YesNo

Has Individual received Medical Care?

What were the recommendations made for care?

YesNo

Has Individual Been Isolated or Quarantined?

Start Date of Isolation or Quarantine

YesNo

Has Individual been tested?

Date of Test

Test Outcome

PositiveNegativePending

YesNo

Has Individual been around others?

Date (if known)

Recent Contact With (Please check all that apply)

Cardinal Member
Cardinal Staff
Staff from Another Provider/Agency

List Name of Agency/Provider and Individual's Name

Provider/Practitioner Operational Questions

Providers must complete the section below in order for Cardinal Innovations to conduct outreach to the provider for follow-up and developments of a plan based on response noted below:

YesNo

Are your current operations affected?

YesNo

Will your program remain operational?

What is the date the program will close?

What is the provider’s plan to continue services?

List Services Impacted

Will service delivery be impacted for all members or only member specific services?

What is the estimated timeframe of the impact the provider anticipates service delivery or operations may be affected?

YesNo

Are there any urgent needs for assistance or resources?

What are the specific needs?

YesNo

Do you need assistance with contacting individuals who may have been exposed?

YesNo

Do you need assistance with daily operations and serving members?

Do you need outreach from a Cardinal Innovations Department? If so, please check the applicable department(s)

Please enter any additional comments needed which are not addressed in the previous sections

COVID-19 Reporting Form

Provider Reporting Provider/Staff Related Information

Provider/Practitioner Operational Questions

Reporting Member/Guardian/Family Exposure/Illness

Reporting Cardinal Staff Member Potential Exposure/Illness