Daily Health Screening Questionnaire

(last updated January 3, 2022)

Employees returning to the office are required to review the questions below prior to their arrival at the office each day and certify completion.

Instructions: 

• Employees who answer “Yes” to any of the questions will be excluded from the workplace for a period of time as indicated as follows and must notify their immediate manager of their absence. 
• Employees who answer “Yes,” to questions 1 or 2 are directed to self-quarantine away from work for 10 days from their last close contact with the infected/quarantining individual.  If a fully vaccinated employee is exposed to an individual with a suspected or confirmed COVID-19 diagnosis, the employee should get tested 5-7 days following a known exposure, self-quarantine away from work pending test results, and wear a mask in public indoor settings for 14 days after exposure or until a negative test result.  However, if fully vaccinated employees are living in the same household as someone who has a suspected or confirmed COVID-19 diagnosis, the employee is directed to self-quarantine from work and test on Day 5 after exposure.  Employees may return to the office if they receive a negative test result 5 days after last exposure.
• Employees who answer “Yes,” to questions 3 or 4 are directed to self-quarantine away from work for 10 days and are encouraged to seek medical care.
• Employees who are confirmed or presumed to be positive may be required to provide a doctor’s note certifying that it is safe for them to return to work. 
• Employees who answer “Yes” to question 5 are directed to self-quarantine away from work for 10 days.

Questions:

1. In the last 10 days, have you knowingly been in close contact with anyone who has been diagnosed as infected with, or is being screened or monitored by a health care provider or public official for, COVID-19?
2. In the last 10 days, have you been in close contact with anyone who has been advised to self-quarantine by a health care provider
3. In the last 10 days, have you tested positive for COVID-19 or been diagnosed as COVID-19 positive by a health care provider?  
4. Are you currently experiencing symptoms of COVID-19, including but not limited to fever (100.4 F, 38 C or higher), chills, cough, shortness of breath or difficulty breathing, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, or diarrhea?   
5. In the last 10 days, have you traveled to or from a location that is covered by a travel advisory that recommends or requires a self-quarantine?  “Travel advisory” is considered an official warning statement issued by a state or local government agency or official which would recommend or require that someone traveling to or from the location self-quarantine for a period of time.  If you have traveled in the past 10 days but are unsure whether the location to or from which you traveled is covered by a travel advisory, please contact Human Resources. Fully vaccinated employees who are NOT symptomatic are not required to self-quarantine upon return from travel.

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