NOAA Lab Access Self-Evaluation Form.pdf

NOAA Fisheries COVID-19 Self-Evaluation Form

Please review each of the questions on the form. If any of your answers are "Yes," do not enter the facility at this time.

1. Have you had any of the following symptoms in the last 10 days?

Fever, Fatigue, Cough, Loss of Appetite, Muscle Aches, Shortness of Breath, Sudden Loss of Smell or Taste, or Metallic Taste in Mouth

Yes No

2. Have you had close contact with someone with confirmed or suspected COVID-19 within the last 10 days?

Yes No

3. Do you live with or have regular contact with someone who works at or frequents an establishment that has had a confirmed or suspected outbreak of COVID-19 in the last 10 days?

Yes No

4. Have you attended any large gatherings (over 10 people) in the last 5 days? Yes No

5. Have you traveled, internationally or domestically, in the last 5 days? Yes No