SHIP COVID-19 Screening Assessment

First Name *

Last Name *

Date of Screening *

SHIP Email *

Manager/Supervisor's Name *

Are you fully vaccinated against COVID-19? *

No

Yes

Are you currently experiencing any of these issues? If yes, call 911 immediately and notify your Manager. Do not continue the screener. *

Severe difficulty breathing (struggling for each breath, can only speak in single words)

Severe chest pain (constant tightness or crushing sensation)

Feeling confused or unsure where you are

Losing consciousness

None of the above symptoms

In the past 14 days have you been directed by a federal border agent to comply with federal quarantine requirements due to international travel? *

No

Yes

In the last 5 days have you experienced any of these symptoms? *

Do any of the following apply? You live with someone who is currently isolating because of a positive COVID-19 test. You live with someone who is currently isolating because of COVID-19 symptoms. You live with someone who is isolating while waiting for COVID-19 test results. Select "No" if you: are 18 or older and have received your booster dose, or are 17 or younger and are fully vaccinated, or completed your isolation after testing positive in the last 90 days (using a rapid antigen, rapid molecular, or PCR test). *

No

Yes

In the last 5 days, have you tested positive on a rapid antigen test, molecular test, or home-based self-testing kit? Select “No” if you have already completed your isolation period of 5 days because your symptoms started before your positive test result, and: you do not have a fever, and your symptoms have been improving for 24 hours (48 hours for nausea, vomiting, and/or diarrhea). *

No

Yes

Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? This can be because of an outbreak or contact tracing. *

No

Yes

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The completion of this COVID-19 screening assessment is a commitment to my health and to the health and well-being of others.

Please complete the form below ensuring your responses are honest and provide an accurate reflection of your current health condition.

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