Attachment 10 CUSFF_NAVNORTH COVID19 Screening Questionnairev2020.04.18.pdf

CUSFF/NAVNORTH COVID-19 Screening Questionnaire

(V2020.04.18)

1. IN THE PAST 24 HOURS, have you had any of the following symptoms? YES NO

a. Fever

b. Cough (not due to allergies)

c. Sore Throat

d. Shortness of Breath

e. Loss of smell or taste

If “YES”, LEAVE/DO NOT ENTER the workplace, GS inform supervisor, CTR inform employer, uniformed personnel inform chain of command, put on a clean mask or cloth face covering and contact/report to your medical provider (call ahead to inform them of your pending arrival). Follow CDC Guidance.1 *Entry denied

2. Have you TRAVELED INTERNATIONALLY in the past 14 days? YES NO

If “YES”, LEAVE/DO NOT ENTER the workplace.

Uniformed personnel: Complete 14 days of ROM.2 *Entry denied

GS/contractor: DO NOT ENTER workplace for 14 days and inform supervisor/employer.2 Follow CDC Guidance.3 *Entry denied

3. Have you TRAVELED DOMESTICALLY (U.S.) outside of your authorized local travel radius in the past 14 days?

YES NO

If “YES”, LEAVE/DO NOT ENTER the workplace.

Uniformed personnel/GS/contractor: DO NOT ENTER workplace and contact supervisor/employer for additional guidance.2

Refer to NMCPHC assessment of state/county specific risk (CAC required).4

4. Have you had CLOSE PERSONAL CONTACT, with anyone who has been YES NO diagnosed with COVID-19 in the past 14 days? (per criteria below)

a. Within 6 feet for prolonged period of time

b. In direct contact with infectious secretions (been coughed/sneezed upon, etc.)

If “YES”, LEAVE/DO NOT ENTER the workplace. Put Put on a clean mask or cloth face covering and contact/report to your medical provider (call ahead to inform them of your pending arrival) for quarantine determination. *Entry denied

5. TEMPERATURE CHECK (due to close proximity, screeners should wear cloth face covering or other mask as available):

a. If temperature is less than 100°F (37.8°C), allow access. Screening is complete.

b. If temperature is equal to or higher than 100°F (37.8°C), LEAVE/DO NOT ENTER the workplace, GS inform supervisor, CTR inform employer, uniformed personnel inform chain of command, put a clean mask on when one is available, and contact/report to your medical provider (call ahead to inform them of your pending arrival). Follow CDC Guidance.1 *Entry denied

ROM: Restriction of Movement 1 https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/steps-when-sick.html 2 OSD Memo Force Health Protection Guidance Supplemental 8 (13 Apr20) 3 https://www.cdc.gov/coronavirus/2019-ncov/travelers/after-travel-precautions.html 4 https://esportal.med.navy.mil/sites/nmcphc/pps/COVID19/COVID19%20State%20Surveillance%20Medical%20Intel.pdf https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/steps-when-sick.html https://www.cdc.gov/coronavirus/2019-ncov/travelers/after-travel-precautions.html