You must use Google Chrome, Safari or Microsoft Edge browsers to submit this form.

This form is for U.S. and Puerto Rico-based employees only. Global employees must open a case with Employee Center.

Complete this form only if you have tested positive for COVID-19 AND potentially exposed others (e.g., colleagues, customers, clients, members) at work or during a work-related event or meeting. You should also complete the form if you believe you were exposed* to COVID-19. For additional information, refer to our  UHG COVID-19 Employee Resources guide. 

*Exposure is defined by the Centers for Disease Control and Prevention (CDC) as follows:

Being within 6 feet of someone with COVID-19 for a total of 15 minutes or more in a day (even if broken into shorter periods) without proper personal protective equipment (PPE).
Having direct contact with respiratory secretions (e.g., being coughed or sneezed on) without proper PPE.
Being present during aerosol-generating procedures (e.g., intubation or suctioning) without 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: