COVID-19 Health Self Screening Form Rev 1 – HIGH BRIDGE ASSOCIATES, INC.

COVID-19 Health Self Screening Questionnaire

NOTE: All Fields Marked with Asterisk (*) are Required

Employee Name (Select from Drop-Down) *

Work Location (Select from Drop-Down) *

Work Day Date *

Health Screening Criteria - Updated 11/5/2020

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 an infected person for a cumulative total of 15 minutes or more over a 24-hour period. Additional factors that will be considered when determining the need for quarantine include proximity, the duration of exposure, presence of symptoms or respiratory aerosols, and other environmental factors.

Answer to Question 4 *

Yes

No

ALERT!!

Question 5

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

Please use this form for work dates 4/20/2020 and later ONLY