Attachment 2 NSWCPD ENTRY SCREENING ASSESSMENT 01 Apr 20.pdf

01 Apr 2020 Revision 2

NSWCPD COVID-19 SCREENING & SELF-ASSESSMENT QUESTIONNAIRE

1. Have you traveled internationally (to include Canada) or within the New York City Metropolitan Area in the last 14 days? YES NO

2. Have you had close personal contact, as defined below, with anyone who has been diagnosed with COVID 19 (lab or clinical diagnosis)? YES NO

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

b. In a confined space (car, small room, shared stateroom, berthing proximity, office, etc.)

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

3. Are you currently experiencing any of the following symptoms?

a. Fever YES NO

b. Chills YES NO

c. Cough YES NO

d. Sore Throat YES NO

e. Shortness of Breath YES NO

f. Body Aches YES NO

Seek medical advice by calling your insurance provided health line number and/or:

• Pennsylvania Department of Public Health: 1.877.724.3258 or visit, health.pa.gov

• New Jersey Department of Public health: 1.800.962.1253 or text, NJCOVID to 898-

211 or visit, NJ.gov/health

• Delaware Department of Public Health: 1.866.408.1899 or email, DPHcall@delaware.gov

In an effort to limit any possible exposure of COVID-19, if you have answered YES to any of the above questions, it is highly recommended that you telework if eligible or take appropriate leave.

mailto:DPHcall@delaware.gov