NOAA MHS COVID-19 Reporting Risk Assessment updated 7JULY2020.pdf

Yes No

COVID-19

Reporting Risk Assessment Form v1.0 7JULY2020

1. Have you had any of the following symptoms in the last 14 days? Fever, Fatigue, Cough, Loss of Appetite, Muscle Aches, Shortness of Breath, Sudden Loss of Smell or Taste

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?:

5. Can you attest to the fact that you have been carrying out best practices and or self-quarantine for at least 14 days?

6. Have you ever been diagnosed or tested for COVID-19?

a. If "Yes"

i. Where:________________________________________

ii. Date of Positive Test:____________________________ Antibody or Diagnostic

iii. Date(s) of Negative Test:_________________________ Antibody or Diagnostic

[Dates/Country/City, including layovers]

Yes No

***Any additional travel before reporting to the ship or any symptoms develop such as Fever, Fatigue, Cough, Loss of Appetite, Muscle Aches, Shortness of Breath, Sudden Loss of Smell/Taste must be reported to Marine Health Services for a re-evaluation of clearance to report to the ship***

Name:___________________________ Email:___________________________ Phone:_______________________________ Ship Reporting to:_________________ When:_______________________________

Wage Mariner NOAA Corps/PHSStatus: (check one)

Interviewed by phone on: ______________

Notified Marine Center CO and Ship CO on: ______________

Reviewed by/Interviewed by (Official Use): _____________________________________ Comments for Official Use:

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