Attachment_J_COVID-19 Screening Questionnaire.pdf

CUSFF/NAVNORTH COVID-19

Screening Questionnaire (V2020.07.16)

1. Temperature Check: Any reading greater than 100.0°F entry not authorized. See ** below.

2. YES or NO, are you currently experiencing any of the following symptoms, that you cannot attribute to another health condition?

• Fever (100.0°F) or sense of having a fever

• Cough

• Shortness of breath or difficulty breathing

• Chills

• Sore throat

• Muscle aches

• Headache

• New loss of taste or smell

3. Have you been tested for the virus that causes COVID-19 with a positive or pending result in the last 14 days?

4. In the past 14 days, have you had close contact (within about 6 feet for 15 minutes or more) with someone with suspected or confirmed COVID-19?

5. Are you arriving/returning from out of the local area in the last 14 days?

(Visitor: Answer 5a through 5e prior to arrival, and send back to command POC)

5a. Are you returning, visiting, PCS'ing from a DoD-designated "red" region?

(see ++ below factor 1 and factor 2 apply)

5b. Did you travel via public transportation (air, train, bus)?

5c. Did you have (plan to have) intermediate stops in a DoD-designated "red" region? (see ++ below factor 1 and factor 2 apply)

5d. What building or spaces are you intending to visit?

(Visitors only. Does not apply to returning staff members.)

5e. What is your visit purpose, including how many people you may interact with?

(Visitors Only. Does not apply to returning staff members.)

Medical recommendation:

**LEAVE/DO NOT ENTER the workplace, civilian employee 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).

No: proceed to question 3.

Yes: see ** below.

No: proceed to question 4.

Yes: see ** below.

No: proceed to question 5.

Yes: see ** below.

No: YOU MAY ENTER.

Yes: proceed to 5a.

++ http://www.mnp.navy.mil/group/don-covid-19-travel-tracker

Supervisor: ROM not feasible/practical (forward to Flag/SES for decision)

First Flag/SES Determination: 14-day ROM ROM not feasible/practical.

(Wear face covering and maintain social distancing throughout visit.)

14-day ROM

ROM not required (recommend entry)14-day ROM

No ROM; entry allowed

No: proceed to question 5b.

Yes: see * below

No: proceed to question 5c.

Yes: see * below

* Leadership review of 14 day ROM (if there are extenuating circumstances.)

Supervisor: 14-day ROM Forward for medical recommendation

No: YOU MAY ENTER.

(if also 'No' to 5a and 5b) Yes: see * below