E1_MSC Screening Questionnaire 20210416.pdf

MSC COVID-19 Screening Questionnaire (V20210416)

1. Are you currently feeling SICK YES NO Have you had any of the following symptoms in the last 24 hours?

a. Fever YES NO

b. Cough (not due to allergies) YES NO

c. Sore Throat YES NO

d. Shortness of Breath

e. New Loss of smell or taste

f. Chills

g. Muscle Pain (not related to physical activity)

h. Headache ** YES NO

If "YES", LEAVE/DO NOT ENTER WORKSPACE/VESSEL, CIVMAR inform Master, Uniformed inform chain-of-command, GS inform supervisor, CTR inform employer. Put a clean mask on when one is available, and contact/report to your medical provider.

Follow CDC guidance (Footnote 1). *Entry denied

** If the only symptom answered “Yes” is headache, refer to Medical or Master for temperature and interview.

2. Have you TRAVELED INTERNATIONALLY in the last 14 days? YES NO If “YES” DO NOT ENTER WORKSPACE/VESSEL – Entry denied MSC Personnel: Complete 14 Days ROM, DO NOT ENTER for 14 days. CIVMAR inform Master, Uniformed inform chain-of-command, GS / CTR inform supervisor (Footnote 2). Follow CDC guidance (Footnote 3). *Entry denied

3. Have you received an approved COVID-19 vaccination? YES NO

a. If YES, did you complete the vaccination series? YES NO

b. If YES, was the series completed more than 2 weeks ago? YES NO

c. If YES, can person produce written/electronic documented proof of vaccination? YES NO

Note 1: If yes to all three questions, allow entry and no further questions required.

Note 2: If no to any question, proceed to question 4

4. Have you been TESTED FOR COVID-19 in the last 14 days? YES NO If “YES” Ask the following: What were the results of that test? Positive/Negative/Still Awaiting Results

If “Positive” or “Still Awaiting Results” – LEAVE/DO NOT ENTER WORKSPACE/VESSEL.

CIVMAR inform Master, Uniformed inform chain-of-command, GS inform supervisor, CTR inform employer (Footnote 2). Entry denied.

Note 1: Refusal to provide an answer to this question shall be considered a “positive” result and treated accordingly.

Note 2: If person was tested as part of completing ROM-Sequester, or for other reasons unrelated to possible contact with COVID- 19, and person is still awaiting test results, they may be permitted entry at the discretion of the Master/Supervisor.

5. Have you TRAVELED OUTSIDE THE LOCAL AREA in the last 14 days? YES NO If "YES", DO NOT ENTER WORKSPACE/VESSEL, Put a clean mask on when one is available, and contact/report to Medical/Master for secondary screening. Follow CDC guidance (Footnote 1). Entry denied.

Note 1: See attached matrix to assist with travel risk assessment in secondary screening.

Note 2: If in CONUS, review assessment of state/county specific risk as part of secondary screening (Footnote 4/CAC required).

6. Have you had CLOSE PERSONAL CONTACT, with anyone who has been YES NO diagnosed with COVID-19 or exhibiting symptoms (fever, cough, sore throat, etc.) in the last 14 days?

If "YES", LEAVE/DO NOT ENTER WORKSPACE/VESSEL, CIVMAR inform Master, Uniformed inform chain-of-command, GS inform supervisor, CTR inform employer. Put a clean mask on when one is available, and contact/report to your medical provider.

Follow CDC guidance (Footnote 1). *Entry denied

7. Once instructed by higher authority, CONDUCT TEMPERATURE CHECKS:

a. If temperature is less than 100°F {37.8°C), allow access. Screening is c o m p l e t e .

b. If temperature is equal to or higher than l00°F (37.8°C), LEAVE/DO NOT ENTER WORKSPACE/VESSEL, CIVMAR inform Master, Uniformed inform chain-of-command, GS inform supervisor, CTR inform employer, put a clean mask on when one is available, and contact/report to your medical provider (call ahead to inform them of your pending arrival). Follow CDC Guidance. (Footnote 1) Entry denied

DENY ENTRY TO ANYONE WHO FAILS TO COOPERATE OR PROVIDE ANSWERS TO THE ABOVE QUESTIONS Footnote 1 https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/steps-when-sick.htm Footnote 2 OSD Memo Force Health Protection Guidance Supplement 8 (13Apr20) Footnote 3 https://www.cdc.gov/coronavirus/2019-ncov/travelers/after-trave1-precautions.htm Footnote 4 https://www.mnp.navy.mil/group/don-covid-19-travel-tracker http://www.cdc.gov/coronavirus/2019-ncov http://www.cdc.gov/coronavirus/2019-ncov http://www.cdc.gov/coronavirus/2019-n http://www.cdc.gov/coronavirus/2019-n