This form should be used by US- and Puerto Rico-based Employees ONLY. Use this form in Google Chrome or Microsoft Edge browsers. Global employees must open a case with HRdirect.

Only complete this form if you have tested positive for COVID-19 or been exposed* to COVID-19. For additional information, please refer to the  UHG COVID-19 Employee Resources site. 

*Exposure is defined as:

Non-patient/member facing: UHG follows the CDC definition for exposure, which is defined as being within 6 feet for a combined total of 15 minutes or more over a 24-hour period (e.g., three 5‐minute exposures for a total of 15 minutes).
Patient/member facing: UHG follows the CDC definition for exposure, which is defined as being within 6 feet for a combined total of 15 minutes or more over a 24-hour period (e.g., three 5‐minute exposures for a total of 15 minutes) without the use of proper PPE.

Who is this case for? Myself Someone Else

Employee Id:

Work Email:

Preferred Email:

Name:

Date of Birth:

Preferred phone number:

I am contacting EOHS because:

Date exposed:

Note: This does not have to be exact and can be your best guess of exposure date.

Date of Positive test:

Did you enter a UHG building, work in the field, or at a client site?

Date last worked onsite:

Where was this site located: