COVID-19 Employee Pre-Assignment Screening Questionnaire (form)

Company

This field is for validation purposes and should be left unchanged.

Please answer the following questions:

Fill out the form below to acknowledge and verify that you have completed COVID-19 self-screening. Integrated Security Services, Inc. will follow all policies regarding the Privacy and Security of Personal Health Information including the use, disclosure, storage and destruction of PHI. If you decline to self-screen using this COVID-19 screening tool, you will be provided with the option of providing alternative proof of your current health status. If you decline to self-screen using either option, you will not be considered for this assignment.

Full Name (required)*

Email (optional)

Have you experienced any of the following symptoms in the past 48 hours:

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

Please select an answer*

Yes

Are you isolating or quarantining because you tested positive for COVID-19 or are worried that you may be sick with COVID-19?

Please select an answer*

Yes

Are you fully vaccinated?* OR Have you recovered from a documented COVID-19 infection in the last 3 months?

*To be considered fully vaccinated, you must be ≥2 weeks following receipt of the second dose in a 2-dose series or ≥2 weeks following receipt of one dose of a single-dose vaccine.

Please select an answer*

Yes

Please upload pictures of your vaccination card, front and back (optional)

Drop files here or

Accepted file types: jpg, gif, png, jpeg, pdf, Max. file size: 15 MB, Max. files: 2.

Have you been in close physical contact* in the last 14 days with:

anyone who is known to have laboratory-confirmed COVID-19?

anyone who has any symptoms consistent with COVID-19?

*Close physical contact is defined as being within 6 feet of an infected/symptomatic person for a cumulative total of 15 minutes or more over a 24-hour period starting from 48 hours before illness onset (or, for asymptomatic individuals, 48 hours prior to test specimen collection).

Please select an answer*

Yes

Are you currently waiting on the results of a COVID-19 test?

IMPORTANT: ANSWER “NO” IF YOU ARE WAITING ON THE RESULTS OF A PRE-TRAVEL OR POST-TRAVEL COVID-19 TEST

Please select an answer*

Yes

Have you traveled* in the past 10 days?

*Travel is defined as any trip that is overnight AND on public transportation (plane, train, bus, Uber, Lyft, cab, etc.) OR any trip that is overnight AND with people who are not in your household.

Please select an answer*

Yes