Berkeley Lab COVID-19 Symptom Check
This form must be completed by all Berkeley Lab badge holders each week prior to accessing ANY LBNL facility. You are REQUIRED to screen yourself each day for COVID-19 symptoms (see below) and if you experience any new symptoms (as compared to your baseline health status), do not report to work at any LBNL location. If you experience any symptoms during the workweek, you must leave the site.
This form completes your record-keeping requirement for the week, but badge holders must certify they will continue to monitor their symptoms each day and not report to the site if they become symptomatic at any point during that week. A new symptom check must be recorded each week beginning on Sunday. A notification that you completed this form will be sent by email to you as well as to your supervisor/host.
The Laboratory recognizes the sensitivities associated with all information related to your health. The symptom check is designed to limit the information collected as much as possible to the information that the Laboratory needs to fulfill its obligations. The symptom check:
-Does not ask or record any information about specific symptoms.
-Does not ask you to submit the check if you have symptoms.
-Is not shared with LBNL Health Services - it is purely an employee/employer transaction.
Employee ID Number (Six Digits)
You are required to self-monitor for these symptoms each day before you enter any LBNL facility. Do not enter any LBNL facility if you have these symptoms (as compared to your baseline health status). Also, if you experience any of these symptoms during the week while at a site, you must leave and follow the instructions for symptomatic people below:
1. Fever (greater than or equal to 100 deg F*) or Chills
3. Shortness of breath or difficulty breathing
5. Muscle or body aches
7. New loss of taste or smell
8. Sore Throat
9. Congestion or runny nose
10. Nausea, vomiting or diarrhea
*Taking your temperature is recommended as the best way to determine fever, but is not required.
If you are experiencing any of the above symptoms DO NOT COME TO ANY LBNL FACILITY until you have been cleared by your Primary Care Physician through LBNL Health Services. If you think you have been exposed, DO NOT COME TO ANY LBNL FACILITY until you have consulted with LBNLs Health Services on how to proceed.
If you have any of the above symptoms:
1. Do not check the box below and do not submit this form
2. Do not report to any LBNL site -- stay home
3. Notify your supervisor if you are unable to report and seek guidance on how to report your time
4. Contact Health Services for advice and potential workplace contact trace
5. Contact your health care provider.
I am symptom free and will self-monitor each day this week before I enter any LBNL site.
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This form was created inside of Berkeley Lab (Univ of California).