NOVEL 2019 Coronavirus(COVID-19) Questionnaire
Please response as accurately as possible in order for us to maintain a safe work environment for all:
Date
Name(First)
Name(Last)
Hanwha(department)
Group
Non-Hanwha(company or organization)
Hanwha(manager)
Name
Number
Contact
Non-Hanwha(Hanwha contact)
Name
Number
#1. Have you traveled outside the United States in the last 2 weeks? ______ YES ______ NO
- If NO, move on to question #2
- If YES, what country(nation) ____________ when(period) _____________
#2. Have you been exposed to a person who was diagnosed with COVID-19? _____ YES _____ NO
- If NO, move on to question #3
- If YES, when was the exposure _______________________________________
#3. Do you currently have a fever of temperature exceeding 100F(37.5C)? ______ YES ______ NO
*Administrator will check body temperature with a non-touch device
I declare that I have answered to the best of my knowledge on the questions above,
and acknowledge that I may be subject to additional screening and/or quarantine before entry.
Signature _________________________ Date __________________
----------------------------------------------------------------------------------------------------------------FOR ADMINISTRATOR(OFFICE) USE ONLY
Question
#1
Question
#2
Question
#3
PASS
FAIL
FAIL if location falls into travel alert category level 2,3,4, and period is within last 2 weeks
MOVE ON TO #2 if location falls into travel alert category level2,3,4, but 2weeks have passed
MOVE ON TO #2 if location does NOT fall into travel alert category level2,3,4
NO MOVE ON TO #2
FAIL if the exposure was within last 2 weeks
YES
MOVE ON TO #3 if 2 weeks have passed since the exposure
NO MOVE ON TO #3
YES FAIL - body temp measures over 100F(37.5C)
NO PASS - body temp measures below 100F(37.5C)
Visitor allowed within Premises immediately
Follow Protocol before entry
YES
*travel alert category : https://www.cdc.gov/coronavirus/2019-ncov/travelers/index.html