NOAA MHS COVID-19 Reporting Risk Assessment updated 2NOV2020.pdf

Yes No

COVID-19

Reporting Risk Assessment Form v1.0 2NOV2020

1. Have you had any of the following symptoms in the last 14 days? Fever, Chills, Cough, Shortness of Breath or Difficulty Breathing, Fatigue, Muscle/Body Aches, Headaches, Sudden Loss of or change in Smell or Taste, Sore Throat, Congestion or Runny Nose, Nausea, Vomiting, Diarrhea

2. Have you been in contact with anyone believed to be infected with COVID-19 (presumptive or confirmed)? (*14 days of quarantine must occur before granting clearance to travel/board*).

3. Have you traveled out of the country in the last 14 days?

If Yes, When/Where?: [Dates/Country/City, including layovers]

4. Have you been tested for COVID-19 in the previous 30 days?

a. If "Yes"

5. In the last 7 days, have you participated in any of the following activities listed below? (Requires 5 days of SIP prior to being granted permission to work aboard a NOAA Vessel).

i. Where:

ii. Date of Positive Test(s):

iii. Date of Negative Test(s):

Antibody or Diagnostic?

Antibody or Diagnostic?

Yes No

Name:

Email: Phone:

Ship Reporting to: When:

Status: (check one) Wage Mariner

If any symptoms listed in question 1 above develop you must report this to Marine Health Services immediately. Everyone should still avoid the above activities in general, wear masks, and avoiding large groups when possible.

Submit this form to your assigned medical officer NLT 5 but no sooner than 8 days before the anticipated work day.

Reviewed/Cleared by (MHS Use): Date:

Contractor/Other

Activities that Pose a Higher Risk of Exposure to COVID-19*** Risk increases with larger crowds, singing, chanting and where it's difficult to stay spaced at least 6ft apart. The longer people are together in these situations, the higher the risk. Weddings, festivals and parades are examples. Included herein are activities from multiple sources that have been deemed activities that put those at higher risk of contracting or spreading COVID-19:

Commercial air travel Public transportation (Buses, Trains) Attending a large music concert Going to a sports stadium Going to an amusement/theme park Attending a religious service Going to a bar Going on a cruise Going to a crowded beach

*Participation in the above activities before reporting to the ship is prohibited*

Going to an indoor gym Eating indoors at a restaurant or buffet Playing high- or full-contact sports (Football, Basketball) Going to casinos Going to a movie theater Other large gatherings (Weddings, Parades, Rallies, Festivals) Playgrounds and summer camps Going to a hair salon or barbershop

Port Eng/ET Scientist

Test Type:

NOAA Corps/PHS

SECB

Contract Co. Name:

Today's Date:

Yes Yes NoNo

Yes Yes NoNo

Yes Yes NoNo

Yes Yes NoNo