AICP Screening Questionnaire

COVID-19 Symptom Screening
Your safety is our top priority. To that end, we are asking the following health screening questions to ensure a safe work environment. Everyone must answer these questions before they arrive to work. Remember, if you are sick or exhibiting symptoms of COVID-19 (fever of 100.4 ̊ or greater, chills, cough, fever, difficulty breathing, muscle aches, sore throat, diarrhea, recent loss of taste or smell), or if someone you live with has been lab-confirmed diagnosed with COVID-19 within the last 14 days, you must not report to work.

Date

What is your first name?

What is your last name?

What project are you working on?

What is your job/position?

Do you live in the same household with, or have you had close contact with someone who in the past 14 days was diagnosed with COVID-19 or had a test confirming they have the virus?

Within the last 10 days have you been diagnosed with COVID-19 or had a test confirming you have the virus?

Have you had any one or more of these symptoms today or within the past 24 hours, which is new or not explained by a pre-existing condition?

Fever of 100.4 ̊ or greater, Chills, or Repeated Shaking/Shivering • Cough • Sore Throat • Shortness of Breath, Difficulty Breathing • Feeling Unusually Weak or Fatigued • Loss of Taste or Smell • Muscle Pain • Headache • Runny or Congested Nose • Diarrhea

Have you traveled internationally within the past 14 days?

Where have you traveled?

By checking 'Yes' below I attest that my answers above are accurate to the best of my knowledge.

By checking 'Yes' below I affirm I will notify COMPANY if there are any changes to my answers that occur after I complete this form, and before I arrive to the work location.

The information in the questionnaire(s) or any report generated from information contained in the questionnaire(s) is the sole property of the Employer. Any designated person that would need to be furnished with this information to carry out their duties must return the information to the Employer and may not retain the information.