ACTS Employee/Visitor COVID-19 Self Screening Questionnaire

ACTS Employee/Visitor COVID-19 Self Screening Questionnaire
You must answer “NO” to all the questions in this questionnaire in order to enter/ work on any ACTS or client site. If you answer “YES” to any of the questions, please DO NOT enter the company’s buildings.

If you experience any symptoms or answer “YES” to any of these questions, you must immediately contact your health care professional or MOHTT for recommended next steps AND notify your manager and HR.
Email
example@example.com
Name *

First Name Last Name
Phone Number *

Area Code Phone Number

1) Have you had any of the following symptoms in the last 24 hours? *

	Yes/No
Cough
Shortness of breath of difficulty breathing

OR at least TWO of the following symptoms in the last 24 hours: *

	Yes/No
Fever (usually 100.4 or higher)
Chills
Repeated shaking with chills
Muscle pain
Headache
Sore throat
New loss of taste or smell

2) In the last 14 days have you: *

	Yes/No
Been in contact with someone who was diagnosed with COVID-19?
Been in close contact with someone who had COVID-19 symptoms ?
Traveled internationally or taken a cruise

If you answered “Yes” to question one, please DO NOT come into work. You should:
- Contact your health care professional or Ministry of Health Trinidad and Tobago and strictly follow their guidelines
- Contact Anti-Corrosion and inform them of your health status, particularly in cases where you have been tested and awaiting results or diagnosis for any COVID-19 testing.
If you answered “Yes” to any part of question two, please DO NOT come into work. You should self quarantine for at least 14 days.
Please select where you reside from the dropdown box below
Employee Declaration *

I certify to the best of my knowledge; the information I have provided is accurate.
Date *

Month Day Year
Date
Should be Empty: