Covid-19 self screen QUESTIONNAIRE

The purpose for this questionnaire is to ensure the safety and health of our workforce at this facility while attempting to mitigate the spread of COVID-19. We are required to ask these daily screening questions before entrance to this building is permitted. We are following recommendations from the Center for Disease Control, the state and the other applicable departments. If your answer is “yes” to any of these screening questions, you may not enter this building unless otherwise directed by the HMS daily representative per applicable state and local guidelines. Please promptly contact your health care provider and seek medical care as applicable, self-quarantine and advise the designated HMS daily representative.. 

Thank you for your understanding and for your time.

 

Name
. Have you experienced any cold or flu symptoms, including but not limited to:
o Fever o Cough o Shortness of breath o Sore throat o Difficulty breathing o Chills o Fatigue o Muscle or body aches o New loss of taste or smell o Congestion or runny nose o Nausea or Vomiting o Diarrhea o New onset severe headache o Respiratory illness If your answer is “yes” to this screening question, you may not enter this building. Please promptly contact your health care provider and seek medical care as applicable, self-quarantine and advise the designated HMS daily representative.
2. Do you have a temperature of 100.4 degrees Fahrenheit (38 degrees Celsius) or higher, after taking your temperature before the start of your workday?
If your answer is “yes” to this screening question, you may not enter this building. Please promptly contact your health care provider and seek medical care as applicable, self-quarantine and advise the designated HMS daily representative.
3. Have you traveled outside of the United States in the last 14 days?
If your answer is “yes” to this screening question, you may not enter this building. Please promptly contact your health care provider and seek medical care as applicable, self-quarantine and advise the designated HMS daily representative.
4. 4. Have you been in close contact with someone diagnosed with COVID-19 in the last 14 days?
If your answer is “yes” to this screening question, please contact the designated HMS daily representative to get further instructions and to determine if entry is permitted, based on applicable state and local guidelines.
5. Have you been in close contact with anyone who has traveled within the last 14 days outside of the United States?
If your answer is “yes” to this screening question, you may not enter this building. Please promptly contact your health care provider and seek medical care as applicable, self-quarantine and advise the designated HMS daily representative.