7/7/2020 COVID-19 SCREENING QUESTIONNAIRE

The safety of our employees and customers is our overriding priority. As the coronavirus (COVID-19) pandemic continues, we are monitoring the situation closely and following the guidance from the Centers for Disease Control and Prevention and local health authorities. In order to prevent the spread of the coronavirus and reduce the potential risk of exposure to our workforce, we are asking everyone to complete and submit this questionnaire prior to entering the worksite or touring a home. Please do not enter the worksite or home until your responses have been reviewed and your entry has been approved.

Please respond to each of the following questions truthfully and to the best of your ability. Your participation is important to help us take precautionary measures to protect you, our other employees and customers.

Name:

Phone Number (mobile/home):

Name of agent you are working with:

Address you are entering/viewing:

Fever (100.4° F/37.8° C or greater as measured by an oral thermometer)

YesNo

Cough

YesNo

Fever (100.4° F/37.8° C or greater as measured by an oral thermometer)

YesNo

Sore throat

YesNo

New loss of taste or smell

YesNo

Chills

YesNo

Head or muscle aches

YesNo

Nausea, diarrhea, vomiting

YesNo

2 - In the past 14 days, have you been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact?

YesNo

3 - In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19?

YesNo

4 - Have you or anyone in your household been tested for COVID-19 and are waiting to receive test results?

YesNo

5 - Have you have tested positive for COVID-19, or are you presumptively positive for COVID-19 based on your health care provider’s assessment or your symptoms?

YesNo

NOTE: If you have tested positive for COVID-19 or have been presumptively positive for COVID-19 based on your health care provider’s assessment or your symptoms, please contact your manager or human resources representative when: (1) you have had no fever for at least 72 hours (3 full days), without the use of fever-reducing medications; (2) your other symptoms have improved; and at least 7 days have elapsed since your symptoms first appeared.

6 - In the past 14 days, have you been on a commercial flight or traveled outside of the United States?

YesNo

7 - In the past 14 days, have you been in close proximity to anyone who has been on a commercial 7 flight or traveled outside of the United States?

YesNo

8 - Is there any reason why you feel you are at higher risk of contracting COVID-19 or experiencing complications from COVID-19 by entering the facility? If “yes”, please provide a brief explanation.

YesNo

Explanation:

9 - Have you entered New York State after 12:01a.m. on June 25, 2020 from one of the “impacted jurisdictions”? As of 12 pm 6/30/20, these impacted states include Alabama, Arkansas, Arizona, California, Delaware, Florida, Georgia, Iowa, Idaho, Kansas, Louisiana, Mississippi, Nevada, North Carolina, Oklahoma, South Carolina, Tennessee, Texas and Utah. For a current list of states impacted, this is the website link. https://coronavirus.health.ny.gov/covid-19-travel-advisory

YesNo

10 - If your answer to #9 is YES, have you self quarantined for a minimum of 14 days after re-entering New York State?

YesNo

I hereby certify that the responses provided above are true and accurate to the best of my knowledge.

Date:

Date

Note: The information collected on this form will be used to determine only whether you may be infected with COVID-19. The information on this form will be maintained as confidential. Any questions should be directed to your manager or your human resources representative.

Signature

COVID-19 SCREENING QUESTIONNAIRE

Representations

Certification