Self-Screening Questionnaire

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Beck Institute COVID-19 Self-Screening Questionnaire/Form

Please enter your first and last name

Please enter today's date (MM/DD/YYYY)

CURRENT SYMPTOMS

In the past 72 hours, have you experienced:

Are you aware of having a temperature of 100.4 or above

Chills

Cough

New shortness of breath or any difficulty breathing

Fatigue

Muscle and/or Body Aches

Headache(s)

New loss of taste and/or smell

Sore throat

Congestion or a runny nose

Nausea, vomiting, or diarrhea

IF YOU ANSWERED “YES” TO ANY OF THE SYMPTOMS LISTED ABOVE, DO NOT GO INTO WORK, AND IMMEDIATELY CONTACT JULIE SNOW-REGAN AND CC CAROLYN HANIF.

ADDITIONAL EXPOSURES

In the past 14 days...

1. Have you had close contact with or cared for someone diagnosed with COVID-19 or with whom you suspect may have COVID-19 within the last 14 days?

2. Have any of your family members or close contacts experienced any of the following symptoms: fever, cough, sore throat, respiratory illness, or difficulty breathing?

3. Have you returned from any of the countries listed on the CDC website as the highest risk of transmission (Level 3)?

4. Have you traveled outside of the state of Pennsylvania?

4a. Please describe which city and state you visited and the purpose of trip.

IMPORTANT: IF YOU ANSWERED “YES” TO ANY OF QUESTIONS 1 – 4 ABOVE, PLEASE CONTACT JULIE SNOW-REGAN AND CC CAROLYN HANIF AND AWAIT FURTHER INSTRUCTION AND/OR FOLLOW-UP INFORMATION REQUESTS.

By checking the below, I acknowledge and agree that...

I acknowledge that if for any reason my answers to my questions above would change (e.g. if you exhibit any new or different symptoms, a country I have visited is added to the CDC list, a new diagnosis is made of a personal contact, etc.), then I will immediately notify Human Resources.

I have truthfully answered all the questions on this questionnaire to the best of my knowledge. I further agree to check my temperature and symptoms daily to determine if my answers to this questionnaire need to be amended or supplemented.

I will be subjected to temperature and general wellness checks, and may be subjected to diagnostic testing, as a condition of employment and prior to commencing work duties at the site. I agree that if determined necessary in the sole judgement of onsite clinical personnel, based on clinical symptoms, medical history, travel history or any other objective or subjective indicator(s), I will submit to COVID-19 diagnostic testing.

I acknowledge that if my temperature exceeds 100.4 °F, or if I exhibit symptoms of COVID-19 as described above, or a diagnostic test returns positive for COVID-19, my access may be denied to the worksite and I will not be eligible to return until I receive a written release from a medical doctor verifying to the Company (in its sole discretion) I am not infected with COVID-19.

I am aware of, acknowledge, and agree to assume any risks associated with potential exposure to COVID-19 by choosing to physically report to work.