Name:

Date:

Company:

1. Have you experienced any below symptoms in the past 14 days? Please reply to
each symptom and provide additional clarification, as required.

Primary COVID-19 symptoms:

Fever >100.4F or feverish?

Shortness of breath?

Cough?

Possible alternate COVID-19 symptoms:

Vomiting?

Sore Throat?

Diarrhea?

Runny nose?

Nausea?

Abdominal pain?

Muscle aches?

Chills?

Headache?

2. If you had primary symptoms stated above consistent with COVID-19, have you
been to a doctor and diagnosed that you did not have COVID-19?

3. Have you had any contact with others confirmed with COVID-19 virus in last 14
days?

4. Have you been tested for COVID-19 and received negative results?
 

5. If you are primary symptom free have you been in larger gathering areas (e.g., job
sites, shopping center, grocery store, gymnasium, etc.) in the last 14 days?

a. What specifically did you do away from home?

b. Were these trips limited to minimal duration to only obtain necessary fuel, food,
medical and other supplies as allowed by local state directives and/or CDC
guidelines?

c. Were you able to apply social distancing (6-foot minimum spacing) during the
entirety of the visit?

d. Did you thoroughly wash or sanitize your hands after the visit?

6. Have you maintained appropriate social distancing (greater than 6-foot

separation) from all individuals, excluding your immediate family or members of your
household?  If No please describe. For example this includes interaction in groups
smaller than 10 and traveling in a vehicle.

7. What job sites have you worked in the past 14 days.

8. Do you have of any other extenuating circumstances where you may be at an

elevated risk of exposing other employees at AEDC White Oak to COVID-19? For
example, you have routine direct contact with family members who work in elevated
risk fields such as medical, first responder, emergency, etc.  If so, please describe.

9. Do you have of any other extenuating circumstances in your personal lives that
may present additional COVID-19 risk factors that could affect you or your families? 
For example, any underlying medical concerns, employee provides routine care for
elderly or other at-risk family members. If so, please describe.