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    2020 0330 Active Screening Questionnaire

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    Rowena Codilla Godoy
    This document provides an active screening questionnaire for COVID-19 that includes taking temperatures and asking individuals 6 questions about symptoms they may have experienced in the last 14 days. If an individual answers yes to any of the questions, they will not be allowed to enter the facility unless approved by a medical professional. The screening process aims to keep the facility safe for employees and the public by reducing the spread of COVID-19.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    2020 0330 Active Screening Questionnaire

    Uploaded by

    Rowena Codilla Godoy
    34 views1 page
    This document provides an active screening questionnaire for COVID-19 that includes taking temperatures and asking individuals 6 questions about symptoms they may have experienced in the last 14 days. If an individual answers yes to any of the questions, they will not be allowed to enter the facility unless approved by a medical professional. The screening process aims to keep the facility safe for employees and the public by reducing the spread of COVID-19.

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    Active Screening Questionnaires

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    2020-0330-active-screening-questionnaire

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    This document provides an active screening questionnaire for COVID-19 that includes taking temperatures and asking individuals 6 questions about symptoms they may have experienced in the last 14 days. If an individual answers yes to any of the questions, they will not be allowed to enter the facility unless approved by a medical professional. The screening process aims to keep the facility safe for employees and the public by reducing the spread of COVID-19.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    34 views1 page

    2020 0330 Active Screening Questionnaire

    Uploaded by

    Rowena Codilla Godoy
    This document provides an active screening questionnaire for COVID-19 that includes taking temperatures and asking individuals 6 questions about symptoms they may have experienced in the last 14 days. If an individual answers yes to any of the questions, they will not be allowed to enter the facility unless approved by a medical professional. The screening process aims to keep the facility safe for employees and the public by reducing the spread of COVID-19.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    COVID-19

    ACTIVE SCREENING QUESTIONNAIRE

    This will be updated as the CDC and WA State Health Department’s information on COVID-19 continues to change.

    Your health and well-being are of the upmost importance and we are taking measures to keep the
    facility/office a safe environment for employees as well as the individuals under our charge and
    the public. Therefore, anyone coming into the facility/office will be screened and part of our
    screening process will include taking their temperature and asking the following questions.

    1. Within the last 14-days, have you experienced a new cough that you cannot attribute to
    another health condition?
    ☐ YES
    ☐ NO

    2. Within the last 14-days, have you experienced new shortness of breath that you cannot
    attribute to another health condition?
    ☐ YES
    ☐ NO

    3. Within the last 14-days, have you experienced a new sore throat that you cannot attribute to
    another health condition?
    ☐ YES
    ☐ NO

    4. Within the last 14-days, have you experienced new muscle aches that you cannot attribute to
    another health condition or a specific activity such as physical exercise?
    ☐ YES
    ☐ NO

    5. Within the last 14-days, have you had a temperature at or above 100.4° or the sense of having
    a fever?
    ☐ YES
    ☐ NO

    6. Within the last 14 days, have you had close contact, without the use of appropriate PPE, with
    someone who is currently sick with suspected or confirmed COVID-19?* (Note: Close
    contact is defined as within 6 feet for more than 10 consecutive minutes)
    ☐ YES
    ☐ NO
    If the individual answers YES to any of the questions they will not be allowed into the
    facility/office unless determined otherwise by a designated DOC medical professional.

    *Facilities identified as being at critical staffing levels in health services may have healthcare workers
    authorized by the HQ Emergency Operations Center to enter the facility under the following guidelines:
    • As long as they remain asymptomatic;
    • Self-monitor symptoms as outlined in the guidance; and
    • Wear a surgical mask at entry and at all times while on facility grounds.

    REVISED 3/30/2020

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