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    Health Screening Declaration (EG) Jun20 Rev.0

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    mitesh
    Employee must complete a COVID-19 screening declaration before returning to work. The form asks if the employee has experienced any COVID-19 symptoms in the past 14 days, been in contact with anyone experiencing symptoms or who tested positive, been tested themselves or feel at higher risk. The employee confirms their responses are true and will report any changes to their contact status or answers.

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    Download as PDF, TXT or read online from Scribd

    Health Screening Declaration (EG) Jun20 Rev.0

    Uploaded by

    mitesh
    19 views1 page
    Employee must complete a COVID-19 screening declaration before returning to work. The form asks if the employee has experienced any COVID-19 symptoms in the past 14 days, been in contact with anyone experiencing symptoms or who tested positive, been tested themselves or feel at higher risk. The employee confirms their responses are true and will report any changes to their contact status or answers.

    Original Title

    Health Screening Declaration (EG) Jun20 rev.0(1)

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    Employee must complete a COVID-19 screening declaration before returning to work. The form asks if the employee has experienced any COVID-19 symptoms in the past 14 days, been in contact with anyone experiencing symptoms or who tested positive, been tested themselves or feel at higher risk. The employee confirms their responses are true and will report any changes to their contact status or answers.

    Copyright:

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

    Health Screening Declaration (EG) Jun20 Rev.0

    Uploaded by

    mitesh
    Employee must complete a COVID-19 screening declaration before returning to work. The form asks if the employee has experienced any COVID-19 symptoms in the past 14 days, been in contact with anyone experiencing symptoms or who tested positive, been tested themselves or feel at higher risk. The employee confirms their responses are true and will report any changes to their contact status or answers.

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    © All Rights Reserved
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    EMPLOYEE COVID-19 SCREENING DECLARATION

    Please complete this form as close to your day of return as possible


    Your safety and that of your colleagues is our overriding priority. Please respond to the following questions truthfully and to the best
    of your ability.

    Please do not travel if you answer ‘Yes’ to any of the questions. If you do answer ‘Yes’, contact us immediately to discuss.

    Question Yes No
    1. In the past 14 days, have you had any of the following new onset symptoms? (These
    symptoms will generally be new and persistent. You may exclude symptoms due to a known
    chronic medical condition you may have such as allergies, asthma, Crohn’s disease, ulcerative
    colitis, migraines, etc.):
    Cough
    Shortness of breath or difficulty breathing
    Fever (100.4° F/ 37.8° C or greater)
    Chills
    Fatigue
    Muscle pain or body aches
    Sore throat
    New loss of taste or smell
    Diarrhea, nausea, or vomiting Headache
    Congestion or running nose
    Other symptoms of COVID-19 (as may be identified by the CDC or other health agencies)
    2. In the past 14 days, have you been in close proximity to anyone who was experiencing any of
    the above symptoms, or has experienced any of the above symptoms since your contact?
    3. In the past 14 days, have you been in close proximity to anyone who has tested positive for
    COVID-19?
    4. Have you been tested for COVID-19 and are waiting to receive test results?

    5. Have you have tested positive for COVID-19, or are you presumptively positive for COVID-19
    based on your doctor’s assessment or your symptoms?
    6. Is there any reason why you feel you are at higher risk of contracting COVID-19 or
    experiencing complications from COVID-19 by returning to work? If “yes”, please provide a
    brief explanation.
    Explanation/Comments:

    Where possible please check your temperature on your day of return to EG and do
    not travel if it is above 100.4F/37.8C

    I confirm that my responses to the questions above are true and correct. I also understand that I must report any change in my COVID-
    19 contact status or other change that affects my answers to the FIS in-country manager.

    Name: Contact number(s):

    Position: Email address:

    Signature:

    Date of signing: Date of Travel:

    Please send this completed form to [email protected] and [email protected]

    health screening declaration (eg) jun20 rev.0.docx

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