COVID-19 Risk Assessment Form.pdf

Yes No

COVID-19

Reporting Risk Assessment Form v1.0 20MAY2020

1. Have you had any of the following symptoms in the last 14 days?

*Fever *Chills, *Fatigue *Cough *Loss of Appetite *Muscle Aches *Shortness of Breath *Sudden Loss of (and/or) *Changes in Taste (and/or) Smell *Feeling Winded on Exertion *Nausea/Vomiting *Night Sweats *Rashes (and/or) *Blisters in Mouth

2. Have you been in contact with anyone believed to be infected with COVID-19 (presumptive or confirmed)? (*14 days of quarantine must occur before granting clearance to travel/board*).

3. Have you traveled out of the country in the last 14 days?

If Yes, When/Where?:

5. Can you attest to the fact that you have been carrying out best practices and or self-quarantine for at least 14 days?

6. Have you ever been screened, diagnosed, or tested for COVID-19?

a. If "Yes"

i. Where:________________________________________

ii. Date of Positive Test:____________________________ Antibody or Diagnostic

iii. Date(s) of Negative Test:_________________________ Antibody or Diagnostic

[Dates/Country/City, including layovers]

Yes No

***Any additional travel before reporting to the ship or any symptoms develop such as Fever, Fatigue, Cough, Loss of Appetite, Muscle Aches, Shortness of Breath, Sudden Loss of Smell/Taste (or any other

Name:___________________________ Email:___________________________ Phone:_______________________________ Ship Reporting to:_________________ When:_______________________________

Wage Mariner NOAA Corps/PHSStatus: (check one)

Interviewed by phone on: ______________

Notified Marine Center CO and Ship CO on: ______________

Reviewed by/Interviewed by (Official Use): _____________________________________ Comments for Official Use:

symptoms listed above) must be reported to Marine Health Services for a re-evaluation of clearance to report to the ship** **PLEASE - DO NOT GET ON THE SHIP WITHOUT THIS CLEARANCE**

Contractor / Name of Business:

k.fath7/20

Kelly.M.Fath Text Box