COVID-19 pre-production self-screening questionnaire
This questionnaire is to be used by employees and subcontractors prior to your FIRST VISIT to the Production site or when returning from more than 5 days OFF Site. The questionnaire must be filled out the day before your arrival on site and submitted before 7:00 PM to allow time for the medical team to analyze potentially problematic cases. Use the Daily Screening Form at On-Site Screening during line-up.
Project Name*
Choose your project name
Date
Jour Mois Année
dd/mm/yyyy Hour Minutes AM/PM Option
Identification
Indentification*
Name Surname
Email*
Job
Home phone
Area code phone number
Cellular phone
Area code phone number
Employer
Company
Name of supervisor
Email of supervisor
IMPORTANT
The purpose of this questionnaire is to minimize the risk of spreading the COVID virus within the film crew.
It is important to answer the questions accurately.
Some answers may limit your access to the site or require further clarification.
If in doubt, please contact the medical team at md@siriusmed.com for more information. A tele-consultation with a health professional may result.
Questions

1. In the past few days, have you had any of the following signs and symptoms (Type A)?*

	YES	NO
Fever ( 38 C or higher) or feeling of fever (chills)
Cough (new or exacerbation of a chronic cough)
Difficulty breathing or chest pain
Loss of sense of smell or taste without nasal congestion

If you answered YES, please specify:
2. Have you had any other symptoms (type B) such as:*
YES NO
Major Fatigue
Headache
Congestion / runny nose
Gastroenteritis (nausea, vomiting, diarrhea)
Result symptoms Type B
3. In the past 14 days, have you been in contact with a suspected COVID-19 positive?*
YES NO
If you answered YES to question 3, please specify the type of contact:
Close contact: from more than 10 minutes cumulatively to less than 2m Close contact: sharing an enclosed space for more than two hours (bedroom, office, car, etc ) Occasional contact: less than 15 minutes of face-to-face contact with a confirmed COVID+ case in the 24 hours prior to the onset of symptoms. Occasional contact: sharing an enclosed space with a confirmed COVID+ case for less than two hours in the 24 hours prior to the onset of symptoms.
4. In the past 14 days, have you been in contact with a confirmed case of COVID-19 positive?*
YES NO
If you answered YES to question 4, please specify the type of contact:
Close contact: from more than 10 minutes cumulatively to less than 2m Close contact: sharing an enclosed space for more than two hours (bedroom, office, car, etc ) Occasional contact: less than 15 minutes of face-to-face contact with a confirmed COVID+ case in the 24 hours prior to the onset of symptoms. Occasional contact: sharing an enclosed space with a confirmed COVID+ case for less than two hours in the 24 hours prior to the onset of symptoms.
Have you been diagnosed with COVID-19 or do you think you've had it?
YES NO
How was the diagnostic made?*
Date of onset of symptoms*
Mois Jour Année
Date
Date of diagnostic test
Mois Jour Année
Date
Do you live with a health care worker ?
YES NO
6. Do you suffer from any of the following conditions (even if these are well controlled)? It is important to note that the presence of one or more of these conditions increases the risk of complications from VIDOC-19 infection but does not prevent you from getting to work.
YES NO
Asthma
Chronic Lung Disease
(chronic bronchitis or emphysema)
Diabetes
High Blood Pressure
Immunosuppression ( from drugs or medical condition )
Heart disease
Age over 70
Medication
Do not take medication for fever or pain (e.g. Tylenol, Advil) less than 6 hours before taking a temperature.
REMINDER
It's important to:
- wash your hands frequently with soap
- respect social distancing measures of 2m as much as possible
- wash reusable PPE and tools after each shift
- Wash clothes regularly and dry them in the dryer.
Consent & validation
I certify to the best of my knowledge that this information is accurate. Also, I consent to have my temperature be verified ( either with non contact or oral thermometer ) by a health officer at the morning screening sessions.
Signature*
Clear
Prepared by SIRIUSMEDx
www.siriusmedx.com
Should be Empty:

	YES	NO
Major Fatigue
Headache
Congestion / runny nose
Gastroenteritis (nausea, vomiting, diarrhea)

	YES	NO
Asthma
Chronic Lung Disease (chronic bronchitis or emphysema)
Diabetes
High Blood Pressure
Immunosuppression ( from drugs or medical condition )
Heart disease
Age over 70

COVID-19 pre-production self-screening questionnaire

Identification

Employer

Questions

Medication

REMINDER

Consent & validation

Prepared by SIRIUSMEDx