National registry of ENT surgeons affected by COVID-19 in the UK Survey

COVID-19 is sadly having a huge impact on the UK ENT community and the situation is evolving rapidly. ENT UK is supporting its members and colleagues with the creation of up-to-date specialty specific guidance www.entuk.org/covid-19

We aim to gather accurate information about ENT surgeons affected by COVID-19 to further inform and assist guidance, PPE and service planning. International collaboration, linking to an international ENT COVID-19 registry, is also planned.

We would like to include both confirmed and suspected cases of COVID-19 in ENT surgeons of all grades, for both members and non-members of ENT UK.

Your input would be highly valuable and greatly appreciated. The information provided will be stored securely and used anonymously.

ENT UK Covid-19 Response Team

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* 1. I am...

Male

Female

Other

Prefer not to say

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* 2. Select one option below, you are...

the affected individual

a departmental colleague

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* 3. Select one option below, your entry today is...

a new entry, relating to recent illness

an update to a previous entry

a new entry, relating to antibody testing

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* 4. Select the statements that apply. Have you/ has the patient recovered?

I have recovered

I have not recovered

The patient recovered

The patient has not recovered

Details:

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* 5. What age is the affected individual? (approximate if not known)

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* 6. What City is the affected individual in? (include the borough if London)

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* 7. What is the sub-specialty of the affected individual?

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* 8. Was hospitalisation required for the affected individual?

Yes

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* 9. Was intensive care admission required for the affected individual?

Yes

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* 10. Has the affected individual since died?

Yes

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* 11. Was COVID-19 of the affected individual confirmed by testing?

Yes

I do not know

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* 12. If known, what date was the affected individual's onset of symptoms?

Select below:

Date

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* 13. If known, what was the affected individual's date of diagnosis?

Select below:

Date

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* 14. Which best describes the likely source of exposure to the affected individual?

Inside the workplace

Outside of the workplace

Unknown

Other (please specify)

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* 15. If known, please give as much information as possible about the exposure (e.g. nature of the source, details or surgery/outpatient activity, other staff affected, PPE used)

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* 16. Please detail below any further information you would like to add:

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* 17. If self-reporting, do you wish to provide contact details and if so, would you be happy to be contacted further?

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* 18. To prevent duplication and to improve accuracy of reporting we require your information and contact details if you are reporting for a colleague, please include your name and email address below:

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* 19. By providing this information I consent for its anonymised national and international use

Agree

Disagree