Pro Safety Team and Office Questionnaire

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If any person is displaying symptoms of illness, do not proceed with this assessment. Please advise the individual to contact their primary healthcare physician. In the event of an emergency situation please contact 9-1-1.

What is your first name? *

What is your last name? *

Who is your employer? *

Have you travelled internationally or domestically in the past 14 days? *

Yes

Have you been in close contact with someone who has a laboratory confirmed case of COVID-19? (Close contact is when: 1. An individual who was within 6 feet of the infected person for a total of 15 minutes or more over a 24-hour period. 2. An individual who had unprotected contact with the infected person’s body fluids and/or secretions, for example, being coughed or sneezed on, sharing utensils or saliva, or providing care without wearing appropriate protective equipment.*Note that a person with COVID-19, is considered to be infectious from 2 days before their symptoms first appeared until they are no longer required to be isolated (as described in Home Isolation Instructions for People with COVID-19). 3. A person with a positive COVID-19 test but no symptoms is considered to be infectious from 2 days before their test was taken until 10 days after their test.) *

Yes

Do you have any of the following symptoms? *

Fever

Chills

Dry Cough

Wet Cough

Difficulty Breathing or Shortness of Breath

Tightness in your chest

Headache

Muscle Aches

Sore throat

Nausea or Vomiting

Fatigue

Runny nose or congestion

New lost of taste or smell

Diarrhea

None

Required

If you do have any of these symptoms, how long have you had them?

Are you currently awaiting the results of a COVID-19 test?

Yes

Clear selection

Have you been informed or learned of a reason that you should take precautions due to a potential exposure to COVID-19 in the last 14 days?

Yes

Clear selection

In the last 14 days, have you been in close contact with someone (within 6 feet for a cumulative total of 15 minutes or more within a 24-hour period) who has told you that the person has been diagnosed with COVID-19 or is awaiting results from a COVID-19 test?

Yes

Clear selection

Have you watched the COVID-19 videos about safety, PPE, and hygiene?

Yes

Clear selection

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