SOW Attachment (2) NSWCPD Entry Screening Assessment.pdf

15 July 2020 Revision 7

NSWCPD COVID-19 SCREENING & SELF-ASSESSMENT QUESTIONNAIRE

1. Have you traveled INTERNATIONALLY (to include Canada) within the last 14 days? YES or 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 or 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 or NO

a. Within 6 feet for prolonged period (~15 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?

Symptoms Yes No Symptoms Yes No

Fever or chills Loss of taste or smell

Shortness of breath Sore throat

Difficulty breathing Congestion or runny nose

Fatigue Nausea

Muscle or body aches Vomiting

Headache Diarrhea

Seek medical advice by calling your insurance provided health line number and/or:

Pennsylvania Department of Public Health: 1.877.724.3258 or visit, health.pa.gov

New Jersey Department of Public health: 1.800.962.1253 or text, NJCOVID to 898-211 or visit, NJ.gov/health

Delaware Department of Public Health: 1.866.408.1899 or email, DPHcall@delaware.gov

If you have answered YES to any of the above questions, it is highly recommended that you telework if eligible or take appropriate leave. You shall also contact your local supervisor/company/NSWCPD POC for final determination.

mailto:DPHcall@delaware.gov neal.j.moran Text Box SOW Attachment (2) Sheet 1 of 1