BEFORE REPORTING TO WORK, REVIEW THE COVID “PROTECT YOURSELF AND OTHERS” CHECKLIST
(IF YOU ANSWER YES TO ANY OF THE THREE (3) SETS OF QUESTIONS BELOW, DO NOT GO TO WORK, ADVISE YOUR SUPERVISOR, SEEK MEDICAL ATTENTION AND TAKE A COVID-19 TEST)

EMPLOYEE: FIRST & LAST NAME & DEPARTMENT*

Date:*

Are you experiencing any of the following?

Extreme difficulty breathing Blue-colored lips or face Severe pain or pressure in the chest Severe constant dizziness or light-headedness Acting confused

Slurred speech Seizures Shortness of breath Inability to lie down because of difficulty breathing Chronic health conditions that you are having difficulty managing because of your current respiratory illness

In the past 14 days have you had close contact with someone who is confirmed as having COVID-19?
A close contact is defined as a person who:

• provided care for the individual, including healthcare workers, family members or other caregivers, or who had other similar close physical contact without consistent and appropriate use of personal protective equipment OR
• Who lived with or otherwise had close prolonged contact (within 6 feet) with the person while they were infectious OR
• Had direct contact with infectious bodily fluids of the person (e.g. was coughed or sneezed on) while not wearing recommended personal protective equipment.
*

Yes No

Are you experiencing any of the following symptoms today?

Fever or feeling feverish Shortness of breath Cough Sore Throat Chills

Repeated shaking with chills Muscle pains Loss of taste or smell Headache

If you answered yes, do not report to work and phone your immediate supervisor.

Contact your health care provider immediately and as is policy provide all necessary documentation to your immediate supervisor before returning to work.

Take these steps to protect yourself and those that you live with:

• Maintain 6 feet of separation when interacting with other individuals.
• If you have to go outside, wear a mask or cloth face covering.
• Wash your hands often with soap and water for at least 20 seconds especially after you have been in a public place, or after blowing your nose, coughing, or sneezing.
• Avoid close contact with people who are sick cover your mouth and nose with a tissue when you cough or sneeze or use the inside of your elbow.