COVID-19 Daily Health Screening Inventory (attachment to AOC Clause AOC52.223-11).pdf

Daily Health Screening Inventory

Version 4.2 Note: This version of the Daily Health Screening Inventory form is for informational purposes only.

The COR will provide the contractor with the most-up-to date form as it becomes available.

Regarding your personal health, please answer the following questions to the best of your ability:

Are you currently experiencing, or have you experienced within the past 10 days any of the following symptoms?

Fever (Temp equal to or greater than 100.4 F) [ ] Yes [ ] No Chills with shaking or teeth chattering [ ] Yes [ ] No Fatigue [ ] Yes [ ] No Muscle or body aches [ ] Yes [ ] No Congestion or runny nose [ ] Yes [ ] No Sore throat [ ] Yes [ ] No Frequent cough [ ] Yes [ ] No Shortness of breath at rest [ ] Yes [ ] No Nausea or vomiting [ ] Yes [ ] No Diarrhea [ ] Yes [ ] No Headache [ ] Yes [ ] No Loss of ability to taste or smell [ ] Yes [ ] No

Are you well, but a member of your household is sick at home with bronchitis-like or cold symptoms?

[ ] Yes [ ] No

Are you or a member of your household awaiting COVID-19 test results (excluding a test solely for the purpose of meeting DC Travel Order 220-110), or have you been told to Isolate or Quarantine by a healthcare provider?

[ ] Yes [ ] No

Have you been in direct close contact with a person with lab confirmed or suspected case of COVID-19 within the past 14 days?

[ ] Yes [ ] No

*Before arriving to work, notify your work center monitor via text or email of your response by indicating I answered no to all questions I answered yes to at least one question.

*If you answered yes to any of the above questions, DO NOT report to work. Stay home and consult your personal physician for further guidance.