COVID-19 Health Self Screening Form Rev 1 Please use this form for work dates 4/20/2020 and later ONLY Survey rev 1 COVID-19 Health Self Screening Questionnaire NOTE: All Fields Marked with Asterisk (*) are Required Employee Name (Select from Drop-Down) * Please Select Alan W Schoenhofer Alejandra Navarro Amy J Odum Andrew G Bowen Anthony A Pelnar Ashley B Perreault Banning M Stack Bill C Neugent Bishop M O'Connell Brenton D Lyles Christopher A McGee Christopher C Lucas Daniel H Nelms Daniel P Seiden Danny T Long Darrell W Radford David L Kirk Jr David M Currid David M Kokochak Dennis E Freeman Dennis S Dorman Donald W Patterson Douglas A Findley Elwood W Woodring James B Hines Jr Jason M Gaines Jason T Gainey Jason T Woodring Jeffrey T Johnson Jerry D Jenkins Jerry E Grubb Jr Jerry P Hickerson John H Hartline John M Beaver Josef J Gingrass Joseph C Gay Joseph Klink Kiet A Nguyen Kimberly M Jones Larry C Adkins Linda A Smith Lindsay S Gainey Lynn H Pickel Mark C Whiting Marquis R McBeath Matthew J Chatham Michael D Hewitt Michael D Irwin Michael D Tindill Michael H Collins Michael Mogilefsky Patrick O Fulp Philip S Townsend Jr Raymond J Keeler Rhett A Jahelka Richard E Stirling Robert A Bousman Robert B Sigler Robert J Johns Robert M Pudish Robin C Simmons Rodney E Cavalieri Ryan L Roosma Sharai M Bauer Sharai M Buchanan Shawn E Brownell Sheerene H Cole Stephen C Zurek Steven E Lee Steven L Harland Steven R Edwards Tamia J Jones Theresa M Jones Thomas J Bousman Thomas O Magruder Timothy C Gibson Timothy H Vaughn Timothy M McLean Vincent L Laform Wendy L. Grannis Wesley S Varner William M Adzima Yancey D Wells Work Location (Select from Drop-Down) * Please Select Office Remote Work Day Date * Health Screening Criteria - Updated MANDATORY, IF YOU ANSWER "YES" TO ANY OF THESE QUESTIONS; o DO NOT enter or remain on a Southern Company site. o Contact your supervisor. o Contact your HBA/WMI HR Point of Contact. o Contact your medical provider. Question 1 Do you have ONE or more of the following symptoms that is unusual for you: fever (temperature of 100.4°F or greater) or feel feverish; cough; shortness of breath/difficulty breathing; chills; repeated shaking with chills; muscle pain; headache; sore throat; loss of taste or smell; congestion or runny nose; nausea or vomiting; diarrhea; or general unwell feeling? Visit the CDC website for the most up-to-date list of symptoms. NOTE: Take your temperature using a reliable thermometer according to the manufacturer’s specifications. Answer to Question 1 * Yes No ALERT!! Question 2 Are you treating fever, aches, and/or pains that are unusual for you with prescription or over-the-counter fever/pain reducers such as Tylenol, Aleve, Motrin, acetaminophen, naproxen sodium, ibuprofen, etc.? Answer to Question 2 * Yes No ALERT!! Question 3 Are you treating a cough that is unusual for you with prescription or over-the-counter cough suppressants, such as Robitussin, Delsym, etc.? Answer to Question 3 * Yes No ALERT!! Question 4 Have you had any close contact with anyone who has, within the last 14 days, been suspected of having or diagnosed with COVID-19? The CDC defines close contact as: •Being within approximately 6 feet of a COVID-19 case for approximately 15 minutes or longer, or •Having direct contact with infectious secretions of a COVID-19 case, such as being coughed on. Answer to Question 4 * Yes No ALERT!! Question 5 Have you traveled internationally in the past 14 days? Answer to Question 5 * Yes No ALERT!! Question 6 Are you currently infected with COVID-19? Answer to Question 6 * Yes No ALERT!! Requirements / Guidelines Requirements: 1. This form is used to assist with self-monitoring for COVID-19. For precautionary purposes, if you answer yes to any of the questions, contact your supervisor for directions prior to coming to work. 2. Once you are asymptomatic, you must contact your Supervision and be cleared to be able to return to work. Guidelines: This does not mean you have the virus. If you think you have been exposed to COVID-19 and/or develop symptoms, please call your healthcare provider for medical advice. Here are some helpful tips to monitor your heath: • Take temperature twice a day • Watch for cough or trouble breathing • Avoid public transportation, taxis, or ride-shares • Avoid crowded places such as shopping centers or movie theaters and limit public activities • Maintain a 6-foot distance from others I agree to comply with the Requirements above. * Agree I certify the information provided is accurate and true to the best of my knowledge * Certify Submit If you are human, leave this field blank.