Truth - Employee COVID-19 Screening Questionnaire

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The safety of our employees is our overriding priority. As the coronavirus (COVID-19) pandemic continues, we are monitoring the situation closely and following the guidance from the Centers for Disease Control and Prevention (CDC) and local health authorities. In order to prevent the spread of the coronavirus and reduce the potential risk of exposure to our workforce, we are asking everyone to complete and submit this questionnaire prior to entering the worksite.

Please read each question carefully and respond to each of the following questions truthfully and to the best of your ability. Your participation is important to help us to take precautionary measures to protect you and our other employees.

Please note that providing inaccurate information about your vaccination status may be grounds for discipline.

Note: The information collected on this form will be maintained as confidential.

Email *

Full Name *

Position *

Work Location *

Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms? (Please take your temperature before you answer this question). *

Fever (100.4º F/37.8ºC or greater as measured by an oral thermometer)

Cough

Shortness of breath or difficulty breathing

Sore throat

New loss of smell and taste

Chills

Headache

Muscle aches

Nausea, diarrhea, or vomiting

None of the above

Required

In the past 14 days, have you been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact? *

Yes

Not to my knowledge

In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19? *

Yes

Not to my knowledge

Have you tested positive for COVID-19, or are you presumptively positive for COVID-19 based on your health care provider's assessment or your symptoms? Note - If you have tested positive for COVID-19 or have been presumptively positive for COVID-19 based on your health care provider's assessment, please contact Labor Relations and Employment Services when: (1) you have had no fever for at least 72 hours (3 full days), without the use of fever-reducing medication; (2) your symptoms have improved; AND at least 7 days have elapsed since your symptoms first appeared. *

Yes

Have you been tested for COVID-19 and are waiting to receive your test results? *

Yes

What was the reason for your being tested? *

In compliance with Executive Order 253 - mandated weekly testing

Close contact - ASYMPTOMATIC

Close contact - SYMPTOMATIC

Experiencing symptoms but was not a close contact

Recent travel

Just wanted to know my status

Not applicable

Required

Are you fully-vaccinated for COVID-19? *

Yes

In the past 14 days, have you been on a commercial flight OR traveled outside of New Jersey and/or the United States? *

Yes

If you have answered yes to the previous question, please advise to which state and/or country YOU have traveled. If you answered no, place N/A on the line below. *

In the past 14 days, have you been in close proximity to anyone who has been on a commercial flight OR traveled outside of New Jersey and/or the United States? *

Yes

Not to my knowledge

If you have answered yes to the previous question, please advise to which state and/or country THE PERSON TO WHOM YOU HAVE BEEN IN CLOSE PROXIMITY has traveled. If you answered no, place N/A on the line below. *

I hereby certify that the responses provided above are true and accurate to the best of my knowledge. (Please type your full name on the line). *

A copy of your responses will be emailed to the address you provided.

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