Ref O CTF COVID-19 Screening Questionnaire_REV2_2020.07.06.pdf

CTF COVID-19 Screening Questionnaire

7 JULY 2020 Revision 2

Name:

Company:

Government POC:

Date:

1. Have you traveled INTERNATIONALLY (to include Canada) within the last 14 days?

YES NO

2. Have you traveled DOMESTICALLY (U.S.) outside of our authorized local travel radius in the past 14 days (including the NYC metro area)? YES NO (As a general rule the local travel radius is defined as 50 miles from the worksite. If the employee lives beyond 50 miles, then the local travel radius is extended for the normally used commute route. For non-swipe contractors/visitors, the NSWCPD POC shall be contacted for final disposition).

3. Have you had close personal contact, as defined below, with anyone who has been diagnosed with COVID 19 (lab or clinical diagnosis)? YES NO

a. Within 6 feet for prolonged period (~10 minutes)

b. In a confined space (car, small room, shared stateroom, berthing proximity, office, etc.)

c. Had direct contact with infectious secretions (been coughed, sneezed on, etc.)

4. Are you currently experiencing any of the following symptoms?

a. Fever YES NO

b. Chills YES NO

c. Shortness of breath (or, difficulty breathing) YES NO

d. Cough (not due to allergies) YES NO

e. Sore throat YES NO

f. Loss of taste or smell YES NO

g. Body aches/muscle pain YES NO

5. What geographical area (city, and state) are you travelling from?

6. What geographical locations have you visited in the last 2 weeks?

CTF COVID-19 Screening Questionnaire

7 JULY 2020 Revision 2

Name:

7. How will you travel to NSWCPD? Will you stop anywhere along the way? Where?

8. What is your home organization's current COVID-19 response posture?

Comments:

9. I have reviewed the CTF COVID 19 Training Package and I will comply with CTF COVID-19 response requirements.

Signature: