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USAG Picatinny COVID-19 SCREENING & SELF-ASSESSMENT QUESTIONNAIRE
PLEASE READ EACH QUESTION CAREFULLY
| Have you experienced any of the following symptoms in the past 48 hours: |
| PLEASE CIRCLE THE ANSWER THAT APPLIES TO YOU |
| Shortness of Breath or Difficulty Breathing |
| YES |
| NO |
| Muscle or Body Aches |
| YES |
| NO |
| New Loss of Taste or Smell |
| YES |
| NO |
| Congestion or Runny Nose |
| YES |
| NO |
| Nausea or Vomiting |
| YES |
| NO |
Within the past 14 days, have you been in close physical contact (6 feet or closer for a cumulative total of 15 minutes) with:
| Anyone who is known to have laboratory-confirmed COVID-19? OR |
| YES |
| NO |
| Anyone who has any symptoms consistent with COVID-19? |
| YES |
| NO |
| Are you isolating or quarantining because you may have been exposed to a person with COVID-19 or are worried that you may be sick with COVID-19? |
| YES |
| NO |
| Are you currently waiting on the results of a COVID-19 test? |
| YES |
| NO |
| Did you answer NO to ALL QUESTIONS? |
| Access to Picatinny Arsenal APPROVED. Please show this to security at the Installation Main Gate and submit copy to the Site Visit POC at the registration. Thank you for helping us protect you and others during this time. |
| Did you answer YES to ANY QUESTION? |
| Access to Picatinny Arsenal NOT APPROVED. Please contact your Healthcare provider for further instructions. |
Name: _______________________________ Organization: _________________________ Phone: _______________________________ Email: _______________________________ Date: ________________________________
Signature: ____________________________
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