OKANG COVID-19 Site Visit Questionaire.docx
DOCX document 16 KB Posted
- Attached to
- Base-wide Roof Repair
- Solicitation number
- W50S8U-20-Q-0005
- Issued by
-
Department of the Army National Guard
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Text version
Oklahoma Air National Guard COVID-19 Risk Assessment
LAST NAME:
FIRST NAME:
DATE:
Risk Assessment: Initial Screening Questions
| 1. |
| Have you had, in the last 14 days, or are currently experiencing any of the symptoms listed below? |
| · Fever > 38°C or subjective fever or 100.4F |
| Yes |
| No |
| · Cough |
| Yes |
| No |
| · Shortness of breath/breathing difficulties |
| Yes |
| No |
· Other symptoms such as muscle aches, fatigue, headache, sore throat, runny nose, diarrhea.
If yes, were you treated by a physician?
Yes
Yes No
No
| 2. |
| Have you traveled outside of the United States or domestically outside your regular commuting area within the last 14 days? |
| Yes |
| No |
| 3. |
| Have you had close contact (face-to-face contact within 2 meters/6 feet) with someone who is ill with cough and/or fever who has traveled internationally within 14 days prior to their illness onset? (Contact may be during travel) |
| Yes |
| No |
| 4. |
| In the last 14 days, have you or someone in your household been in close contact with someone directed to self-quarantine or who is symptomatic with laboratory-confirmed COVID-19? |
| Yes |
| No |
| 5. |
| Have you attended a gathering of 500 or more people where social distancing was not possible? |
| Yes |
| No |
If all answers are "NO", the member may attend the site visit.
If any of the above answers are “YES” do not attend the Tulsa ANG site visit. Please send a company representative that can answer “No” to all of the above questions.
Signature / DATE:
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