KML Health Status Survey

Date

Name

Affiliation (or Organization):

KML Arrival Date:

Date of COVID Test: *

COVID Test Result *

Negative
Positive

I 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)

Yes
No

CDC High Risk Categories: https://www.cdc.gov/COVID-19/2019-ncov/need-extra-precautions/groups-at-higher-risk.html

In the past 24 hours, have you had any of the symptoms listed below? *

Yes
No

Fever, sore throat, loss of smell or taste, cough, shortness of breath

Please inform Group lead/PI and KML Staff

Acknowledge

Follow CDC guidance and seek medical treatment/advice. FIO to further conduct risk assessment.

In the past 14 days have you traveled domestically to/from an area designated as Level II (or higher) by the CDC? *

Yes
No

CDC'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 Staff

Acknowledge

Follow 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
No

A. Within 6 feet for a prolonged period B. In direct contact with infectious secretions (coughing, sneezing)

Please inform Group lead/PI and KML Staff

Acknowledge

Have you previously been tested for COVID-19? *

Yes
No

Date of positive COVID-19 test

TEMPERATURE 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.

TWICE DAILY TEMPERATURE CHECKS (Required) *

Acknowledge

I will comply with twice daily temperature checks.

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