Model Screening Questionnaire
May 18, 2020 – Advisories*Employees who provide an answer to the following questions OTHER than the REQUIRED ANSWER may NOT return to the workplace UNTIL they are able to answer the questionnaire with all REQUIRED ANSWERS. For daily screenings of employees, only questions 2–6 must be asked.
- Have you been self-isolating (and following social distance and face-covering protocol when leaving your residence) for the past 14 days, alone or with others, all of whom also have been self-isolating?
- REQUIRED ANSWER: YES.
- Have you had any symptoms of COVID-19 in the past 14 days? Symptoms include any flu-like symptoms, fever, cough, shortness of breath or difficulty breathing, chills and/or repeated shaking with chills, muscle pain, headache, sore throat, loss of sense of smell or taste.
- REQUIRED ANSWER: NO ORYES and the employee has otherwise received clearance from a qualified medical professional to return to work.
- Have you been in contact with anyone in the past 14 days who, in that time period, has exhibited or reported experiencing symptoms of COVID-19?
- REQUIRED ANSWER: NO.
- Have you received a positive test result for COVID-19 and NOT subsequently received a negative test result?
- REQUIRED ANSWER: NO ORYES and the employee has otherwise received clearance from a qualified medical professional to return to work.
- Have you been in contact with anyone in the past 14 days who, in that time period, received a positive test result for COVID-19?
- REQUIRED ANSWER: NO.
- Have you traveled on a bus, train, plane, or other forms of public transportation (other than for commuting to work or for approved work purposes) in the past 14 days?
- REQUIRED ANSWER: NO.