Spec Category Daily Screening Form - LIVE - Feb 2023

Special Category Associates, Volunteers & Visitors

(individuals who do not have an Employee ID #)

OH COVID Screening Tool

Daily COVID screening was discontinued on 2/23/2023.

CNH or HSC contractors, volunteers, or visiting scholars may use the form below to

report COVID symptoms
report a COVID exposure
report a positive COVID test
complete symptom screening after international travel

Date/Time

Name*

First Name

Last Name

Date of birth

Preferred Email (work or personal)*

Phone (cell # preferable)*

Children's National or HSC Department*

Children's National or HSC Direct Supervisor*

First Name

Last Name

Children's National Direct supervisor's email address*

Please ask your CN Direct supervisor for their email address if you do not know it

As identified by the CDC, possible concerning infectious symptoms include fever or chills, cough, shortness of breath or difficulty breathing, loss of sense of smell or taste, extreme fatigue, muscle or body aches, headache, sore throat, congestion or runny nose, nausea or vomiting, and/or diarrhea.

Are you experiencing any of the symptoms listed above, which are new or not typical for you?*

Yes No

What is the date of onset of your symptoms?*

COVID-19 exposure is defined as being within 6 feet of a person with known COVID-19 (without proper PPE) for a sum total of 15 minutes or more over a 24-hour period.

Have you been in close contact with anyone who has tested positive for COVID-19 that has not been previously reported to Occupational Health? *

Yes No

When did this COVID-19 exposure occur?*

Where did the COVID-19 exposure occur?*

Household Community Occupational

In the past 14 days, have you traveled internationally?*

YES No

Where was your primary destination of travel?*

When did you return home after your recent travel?*

Have you recently taken a COVID test that has not been previously reported to occupational health?*

Yes No

Result*

Positive Negative Pending

What date did you take your COVID-19 test?*

Any additional information that you would like to provide to Occupational Health: