Please ensure Health Status Survey is completed prior to arrival at KML. Contact Lisa Tipsword if you have any questions. Please enable JavaScript in your browser to complete this form.Date NameAffiliation (or Organization): KML Arrival Date: Date of COVID Test: *COVID Test Result *Negative PositiveI have read and understand the 'FIO Operations COVID Reopening Actions & Expectations'Are you in a CDC High Risk Category? (Group lead/PI compile and provide with FURF)YesNoCDC High Risk Categories: https://www.cdc.gov/COVID-19/2019-ncov/need-extra-precautions/groups-at-higher-risk.htmlIn the past 24 hours, have you had any of the symptoms listed below? *YesNoFever, sore throat, loss of smell or taste, cough, shortness of breathPlease inform Group lead/PI and KML StaffAcknowledgeFollow CDC guidance and seek medical treatment/advice. FIO to further conduct risk assessment. In the past 24 hours have you traveled to/from an area designated as Level II (or higher) by the CDC? *YesNoCDC's Risk Assessment Levels by Destination: https://www.cdc.gov/coronavirus/2019-ncov/travelers/map-and-travel-notices.html#travel-2 Please inform Group lead/PI and KML StaffAcknowledgeFollow CDC guidance and seek medical treatment/advice. FIO to further conduct risk assessment. In the past 14 days have you had close personal contact with anyone who has been diagnosed with COVID-19? (Per criteria listed below) *Yes NoA. Within 6 feet for a prolonged period B. In direct contact with infectious secretions (coughing, sneezing) Please inform Group lead/PI and KML StaffAcknowledgeHave you previously been tested for COVID-19? *YesNoDate of positive COVID-19 testTEMPERATURE CHECK (Required) *Acknowledge*Screeners should wear mask to conduct temerature screening* If temperature is less than 100 degrees fahrenheit, allow access. Screening complete. If temperature is equal to or higher than 100 degrees fahrenheit, inform group lead/PI and KML staff, replace mask with clean one, and contact a medical provider. DAILY TEMPERATURE CHECKS (Required) *AcknowledgeI will comply with twice daily temperature checks. Submit
