Attachment C - Self-Screening Questionnaire Rev21.08.05.pdf

REV20210805

TODAY’S DATE: _____________

CDC FACILITIES COVID-19 SCREENING

Accessible version available at https://www.cdc.gov/screening/

PLEASE READ EACH

QUESTION CAREFULLY

PLEASE CIRCLE THE ANSWER THAT APPLIES

TO YOU AND FOLLOW THE INSTRUCTIONS

BASED ON YOUR RESPONSE

1. Have you experienced any of the following symptoms in the past 48 hours:

• fever or chills

• cough

• shortness of breath or difficulty breathing

• fatigue

• muscle or body aches

• headache

• new loss of taste or smell

• sore throat

• congestion or runny nose

• nausea or vomiting

• diarrhea

YES

Access to CDC Facilities

NOT APPROVED

NO

Proceed to Question 2

If you have had any of the above symptoms in the last 48 hours, DO NOT physically return to the workplace until symptoms have subsided for more than 48 hours. If you have a chronic medical condition that causes COVID-19-like symptoms and you need access to a CDC facility within the next few days, please obtain medical documentation from your primary care physician and then call CDC’s Occupational Health Clinic (OHC) at 404-639-3385 to determine whether you can safely be granted access to a CDC facility. Fully vaccinated individuals should not access campus if they are currently experiencing any of the above symptoms. If you have an urgent need to access a CDC facility while experiencing any of the above symptoms, please contact your CIO management officer and ask them to request a waiver through OHC. Waivers will only be granted in exigent circumstances and only if it is safe to do so. OHC will not respond to waiver requests made by individuals. Fully vaccinated individuals with symptoms will also require a waiver and should also work through their CIO management officer.

2. Are you isolating or quarantining because you tested positive for COVID-19 or are worried that you may be sick with

COVID-19?

NO

Proceed to Question 3

If you have concerns about being exposed to or sick with COVID-19, please stay home and self-quarantine or isolate.

Read more about when you should be in isolation or quarantine (https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/quarantine.html). If you have questions about when it is safe to return to the workplace, please call CDC’s

Occupational Health Clinic (OHC) at 404-639-3385. If you have an urgent need to access a CDC facility while quarantining, please contact your CIO management officer and ask them to request a waiver through OHC. Waivers will only be granted in exigent circumstances and only if it is safe to do so. OHC will not respond to waiver requests made by individuals. Fully vaccinated individuals will also require a waiver and should also work through their CIO management officer.

STOP

3. Are you fully vaccinated AND/OR have you recovered from a documented COVID-19 infection in the last 3 months?

To be considered fully vaccinated, you must be ≥2 weeks following receipt of the second dose in a 2-dose series or ≥2 weeks following receipt of one dose of a single-dose vaccine.

YES

Proceed to Question 4

NO

Proceed to Question 4

PREFER NOT TO

ANSWER

Proceed to Question 4

4. Have you been in close physical contact in the last 14 days with:

• Anyone who is known to have laboratory-confirmed COVID-19?

OR

• Anyone who has any symptoms consistent with COVID-19?

Close physical contact is defined as being within 6 feet of an infected/symptomatic person for a cumulative total of 15 minutes or more over a 24-hour period starting from 48 hours before illness onset (or, for asymptomatic individuals, 48 hours prior to test specimen collection).

YES

If You are Fully Vaccinated, Proceed to

Question 5

If You are Not Fully Vaccinated or Prefer

Not to Answer

NO

If You are Fully Vaccinated, Proceed to the Certification Step

Below

Access to CDC Facilities

APPROVED

If You are Not Fully Vaccinated or Prefer

Not to Answer, Proceed to Question 6

If you have been in close contact with someone with COVID-19 and you are not fully vaccinated, you should stay home and self-quarantine for 14 days before returning to work. Read more about when you should be in isolation or quarantine (https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/quarantine.html). If you have been in close contact with someone with COVID-19 and you are fully vaccinated, you should stay home and get tested 3-5 days after your exposure, even if you don’t have symptoms. Read more about what to do if you’ve had a close contact and are fully vaccinated (https://www.cdc.gov/coronavirus/2019-ncov/vaccines/fully-vaccinated.html). If you have an urgent need to end your quarantine early to access a CDC facility, please contact your CIO management officer and ask them to email a request to OHC.

5. Were you tested 3-5 days after your exposure with the close contact?

YES

Proceed to the Certification Step Below

Access to CDC Facilities

APPROVED

NO

6. Are you currently waiting on the results of a COVID-19 test?

IMPORTANT: ANSWER “NO” IF YOU

ARE WAITING ON THE RESULTS OF

A PRE-TRAVEL OR POST-TRAVEL

COVID-19 TEST

NO

Proceed to Question 7

If you have an urgent need to access a CDC facility while waiting for a test result, please contact your CIO management officer and ask them to request a waiver through CDC’s Occupational Health Clinic (OHC). Waivers will only be granted in exigent circumstances and only if it is safe to do so. OHC will not respond to waiver requests made by individuals.

7. Have you traveled in the past 10 days?

Travel is defined as any trip that is overnight AND on public transportation (plane, train, bus, Uber, Lyft, cab, etc.) OR any trip that is overnight AND with people who are not in your household.

NO

Proceed to the Certification Step Below

Access to CDC Facilities

APPROVED

If you have an urgent need to access a CDC facility during your 10-day, post-travel self-quarantine (https://www.cdc.gov/coronavirus/2019-ncov/travelers/after-travel-precautions.html), please contact your CIO management officer and ask them to request a waiver through CDC’s Occupational Health Clinic (OHC). Waivers will only be granted in exigent circumstances and only if it is safe to do so. OHC will not respond to waiver requests made by individuals. It is possible to reduce your post-travel self-quarantine (https://www.cdc.gov/coronavirus/2019-ncov/travelers/after-travel-precautions.html), to 7 days if you have a negative viral test (https://www.cdc.gov/coronavirus/2019-ncov/testing/diagnostic-testing.html) 3-5 days after travel (https://www.cdc.gov/coronavirus/2019-ncov/travelers/testing-air-travel.html). OHC can help arrange testing, if needed. A waiver is needed from OHC to reduce your quarantine period.

I certify that my responses are true and correct cdc.gov/screening cdc.gov/screening/further-instructions.html https://www.cdc.gov/screening

THE SCREENING YOU COMPLETED INDICATES THAT

YOU MAY BE AT INCREASED RISK FOR COVID-19

IF YOU ARE NOT FEELING WELL, WE HOPE THAT YOU FEEL BETTER SOON!

Here are instructions for what to do next

If you are not already at home, please avoid contact with others and go straight home immediately.

Seek medical care as needed. Seek COVID-19 testing as recommended. Call CDC’s Occupational Health Clinic (OHC) at 404-639-3385 to schedule testing at CDC in the Atlanta area.

Contact your supervisor or your contracting company to discuss options for telework and/or leave.

Before going to a healthcare facility, please call and let them know that you may have an increased risk for COVID-19.

In case of a life-threatening medical emergency, dial 911 immediately!

RETURNING TO THE WORKPLACE

If you have had symptoms consistent with COVID-19 or have tested positive for COVID-19, DO NOT physically return to work until you have completed your quarantine (https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/quarantine.html) or isolation (https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/isolation.html) per

CDC guidance. Read more about when it is safe to be around others (https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/end-home-isolation.html).

If you have a chronic medical condition that causes COVID-19-like symptoms and you need to access a CDC facility within the next few days, please first get medical documentation from your primary care provider and then call OHC to determine whether you can safely be granted access to a CDC facility.

If you have been in close contact with someone with COVID-19 and you are not fully vaccinated, you should stay home and self-quarantine for 14 days before returning to work. Read more about when you should be in isolation or quarantine (https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/quarantine.html). If you have been in close contact with someone with COVID-19 and you are fully vaccinated, you should stay home and get tested 3-5 days after your exposure, even if you don’t have symptoms. Read more about what to do if you’ve had a close contact and are fully vaccinated (https://www.cdc.gov/coronavirus/2019-ncov/vaccines/fully-vaccinated.html). If you have an urgent need to end your quarantine early to access a CDC facility, please contact your CIO management officer and ask them to email a request to OHC.

If you are currently isolating or quarantining because of concerns about COVID-19, please do not return to the workplace until you have completed your quarantine (https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/quarantine.html) or isolation (https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/isolation.html) per CDC guidance. If you have an urgent need to end your quarantine early, please contact your CIO management officer and ask them to email a request to OHC.

If you are waiting on the results of a COVID-19 test, please do not return to the workplace until you have received a negative test result and have completed any necessary quarantine or isolation per CDC guidance. If you have an urgent need to access a CDC facility while waiting for a test result, please contact your CIO management officer and ask them to email OHC.

If you have additional questions about when you can safely return to work, please call OHC at 404-639-3385. For information about

COVID-19 and basic instructions to prevent the spread of disease, visit CDC’s COVID-19 website (https://www.cdc.gov/covid19).

1 2