Attachment 12 CUSFF_Screening and Self Assessment Form_COVID_3-25-20.pdf

PUGET SOUND NAVAL SHIPYARD & INTERMEDIATE MAINTENANCE FACILITY

1. ARE YOU CURRENTLY SICK with any of the following symptoms? YES NO

a. Fever

b. Cough

c. Sore Throat

d. Shortness of Breath

If “YES”, LEAVE/DO NOT ENTER the workplace, Civilians, inform supervisor, CTR inform employer, 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

2. Have you traveled internationally in the last 14 days? YES NO

If “YES”, LEAVE/DO NOT Uniformed Personnel: Complete 14 days of ROM.2 *Entry Denied

ENTER the workplace. Civilian/CTR: DO NOT ENTER workplace for 14 days, Civilians inform supervisor, CTR inform employer. 2 Follow CDC Guidance. 3 *Entry Denied

3. Have you traveled domestically (U.S.) in the last 14 days? YES NO

If “YES”, self-monitor for fever, cough, difficulty breathing. To extent possible, implement social distancing. If symptoms develop, immediately contact/report to your medical provider (call ahead to inform them of your pending arrival). Follow CDC Guidance. 1

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

a. Within 6 feet for prolonged period (~10 minutes)

b. Had direct contact with infectious secretions (been coughed, sneezed on, etc.)

If “YES”, LEAVE/DO NOT ENTER the workplace. 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) for quarantine determination. *Entry Denied.

5. Once instructed by higher authority to conduct TEMPERATURE CHECKS:

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, civilians inform supervisor, CTR inform employer, 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 SUP 4 (11MARCH20) 3 https://www.cdc.gov/coronavirus/2019-ncov/travelers/after-travel-precautions.html Form from CUSFF/NAVNORTH COVID-19 Screening Questionaire (V2020.03.17) 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