Attachment (4) NSWCPD Entry Screening Assessment.docx

30 NOVEMBER 2021

Revision 12

NSWCPD COVID-19 SCREENING & SELF-ASSESSMENT QUESTIONNAIRE

If you answered YES proceed to question 4. YES or NO

2. Have you traveled INTERNATIONALLY (to include Canada) within the last 14 days? YES or NO

3. Have you traveled DOMESTICALLY (U.S.) outside of our authorized local travel radius in the past 14 days? (As a general rule the local travel radius is defined as 50 miles from the worksite. If the employee lives beyond 50 miles, then the local travel radius is extended for the normally used commute route. For non-swipe contractors/visitors, the NSWCPD POC shall be contacted for final disposition). YES or NO

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

a. Within 6 feet for a cumulative of 15 minutes within a 24 hour period

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.)

5 Are you isolating or quarantining because you may have been exposed to a person with COVID-19 (within the last 72 hours for vaccinated employees) or are worried that you may be sick with COVID-19? YES or NO

6. Are you currently waiting on the results of a COVID-19 test due to suspected exposure to the virus or based on experiencing the symptoms below? YES or NO

7. In the last 14 days, have you experienced any of the following symptoms:

Fever or chills

Loss of taste or smell

Shortness of breath

Sore throat

Difficulty breathing

Congestion or runny nose

Fatigue

Nausea

Muscle or body aches

Vomiting

Headache

Diarrhea

Seek medical advice by calling your insurance provided health line number.If you have answered YES to Questions 2-7 or have tested positive for COVID-19 in the last 14 days, DO NOT ENTER the building and contact your direct supervisor/company for further direction.

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