COVID Questionnaire.docx

COVID-19

ACTIVE SCREENING QUESTIONNAIRE

This will be updated as the CDC and WA State Health Department’s information on COVID-19 continues to change.

Your health and well-being are of the upmost importance and we are taking measures to keep the facility/office a safe environment for employees as well as the individuals under our charge and the public. Therefore, anyone coming into the facility/office will be screened and part of our screening process will include taking their temperature and asking the following questions.

1.) Within the last 14-days, have you experienced a new cough that you cannot attribute to another health condition?

2.) Within the last 14-days, have you experienced new shortness of breath that you cannot attribute to another health condition?

3.) Within the last 14-days, have you experienced a new sore throat that you cannot attribute to another health condition?

4.) Within the last 14-days, have you experienced new muscle aches that you cannot attribute to another health condition or a specific activity such as physical exercise?

5.) Within the last 14-days, have you had a temperature at or above 100.4 or the sense of having a fever?

6.) Within the last 14-days, have you had close contact, without the use of appropriate PPE, with someone who is currently sick with suspected or confirmed COVID-19?* (Note: Close contact is defined as within 6 feet for more than 10 consecutive minutes)

If the individual answers YES to any of the questions they will not be allow into the facility/office unless determined otherwise by a designated DOC medical professional.

*Facilities identified as being at critical staff levels in health services may have health care workers authorized by the HQ Emergency Operations Center to enter the facility under the following guidelines:

· As long as they remain asymptomatic;

· Self-monitor symptoms as outlined in the guidance; and

· Wear a surgical mask at entry and at all times while on facility grounds.