COVID Screening Questionnaire JUL 2020.pdf

COVID-19 SCREENING QUESTIONNAIRE

IF YOU ARE UNSURE OF ANY OF THE ABOVE QUESTIONS

PLEASE CONTACT YOUR CHAIN OF COMMAND

PRIOR TO TRAVEL TO DISCUSS THE RISK

1. ARE YOUR CURRENTLY ILL/EXPERIENCING any of the following symptoms: YES NO

● Fever or Chills ● Headaches ● Shortness of Breath

● Cough ● Muscle or body aches ● New loss of taste or smell

● Sore Throat ● Diarrhea or abdominal pain ● Congestion or runny nose

● Fatigue

If “YES”, DENY ENTRY to the workplace.

Report to Medical Department Representative/command designated person

2. Have you had CLOSE PERSONAL CONTACT, with anyone who has been YES NO diagnosed with COVID-19 or awaiting COVID-19 test results in the past 14 days? (per criteria below)

a. Within 6 feet for >15 minutes

b. In direct contact with infectious secretions (been coughed/sneezed upon, etc.)

c. Without proper personal protective equipment (First Responder, Medical Personnel, Prison Guards, Police Officers, etc.)

If “YES”, DENY ENTRY to the workplace.

Report to Medical Department Representative/command designated person

3. Have you tested positive for COVID-19 or awaiting COVID-19 test results? YES NO

If “YES”, DENY ENTRY to the workplace.

Report to Medical Department Representative/command designated person

4. Have you TRAVELED INTERNATIONALLY in the past 14 days? YES NO

If “YES”, DENY ENTRY to the workplace.

Report to Medical Department Representative/command designated person

Uniformed personnel complete 14 days of Restriction of Movement.

5. If conducting TEMPERATURE CHECKS:

a. If temperature is less than 100.4°F (37.8°C), allow access. Screening is complete.

b. If temperature is equal to or higher than 100.4°F (37.8°C), DENY ENTRY, provide individual a mask (if available) and have them contact their medical provider per local protocols.

Remember to adhere to the following:

Stay home if symptoms develop and immediately contact your medical provider per local protocols

Frequently disinfect hands using soap and water or hand sanitizer

Proper and consistent use of cloth face coverings

Adhere to social distancing (6 feet apart)

Frequently clean and disinfect common touch points (gym, keyboards, laptops, door handles)

Service member Information

Printed Name: ___________________________

Signature: ______________________________

DODI ID Number: __________________________

Reviewer Information

Printed Name: ___________________________

Signature: ______________________________

Date: __________________________________