COVID-19 Daily Onsite Self-assessment Questionnaire - Facility Access

COVID-19 Onsite Daily Self-Assessment Questionnaire

Full Name *

Job Title *

Planned working location(s) *

Planned working location(s) Other (please specify)

People with COVID-19 have had a wide range of symptoms reported – ranging from mild symptoms to severe illness.

Symptoms may appear 2-14 days after exposure to the virus. People with these symptoms may have COVID-19:

Fever or chills*
Cough*
Shortness of breath or difficulty breathing*
Fatigue
Muscle or body aches
Headache
New loss of taste or smell
Sore throat
Congestion or runny nose
Nausea or vomiting
Diarrhea

*common symptoms

If you are experiencing these common symptoms, seek medical care. You cannot enter the facility. Please contact LP3 Network. If you are currently on site, please inform any LP3 Network staff member immediately. You should monitor your temperature regularly to measure your current health status.

Please answer all questions below.

1. Are you currently experiencing or have experienced any symptoms related to COVID-19 within the last 14 days? *

Call your health care provider or public health hotline to discuss symptoms. You cannot enter the facility. Please contact LP3 Network or if you are onsite, please inform any LP3 Network staff member immediately to discuss your situation.

2. Have you been in physical contact with a positive COVID-19 infected person or someone experiencing symptoms related to COVID-19 within the last 14 days? *

Yes

No

Call your health care provider or public health hotline to discuss symptoms. You cannot enter the facility. Please contact LP3 Network or if you are onsite, please inform any LP3 Network staff member immediately to discuss your situation.

3. Have you traveled abroad recently (last 14 days)? *

Yes

No

Call your health care provider or public health hotline to discuss symptoms. You cannot enter the facility. Please contact LP3 Network or if you are onsite, please inform any LP3 Network staff member immediately to discuss your situation.

4. Do you currently have a fever? *

Yes

No

Call your health care provider or public health hotline to discuss symptoms. You cannot enter the facility. Please contact LP3 Network or if you are onsite, please inform any LP3 Network staff member immediately to discuss your situation.

5. Are there any reasons, specific to you, that would prevent you from following the above protocols (e.g., wearing a face mask at all times)? *

Yes

No

5.a - Yes *

Please explain and an LP3 Network staff member will contact you to discuss your personal situation. If you are on site, please inform an LP3 Network staff member immediately.

You can enter the facility, while self-monitoring your state of health.

6. If COVID-19 symptoms present themselves during the day, do you agree to remove yourself from the facility, even if your work has not concluded, seek medical attention and inform LP3 Network of the results? *

Yes

No

You cannot enter the facility. Please contact LP3 Network or if you are onsite, please inform any LP3 Network staff member immediately to discuss your situation.

7. If you test positive for SARS-CoV-2 within 14 days of your last entry to the facility, do you agree to inform LP3 Network and share the results? *

Yes

No

You cannot enter the facility. Please contact LP3 Network or if you are onsite, please inform any LP3 Network staff member immediately to discuss your situation.

You are here

COVID-19 Daily Onsite Self-assessment Questionnaire - Facility Access

COVID-19 Onsite Daily Self-Assessment Questionnaire

Please answer all questions below.