COVID Screening Questionnaire - TEG

Name *

Date of Submission *

Have you or anyone in your household had any of the following symptoms in the last 21 days: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever at or greater than 100 degrees Fahrenheit? *

If yes, please explain or describe in further detail: *

Have you or anyone in your household been tested for COVID-19 in the last two weeks? *

If yes, please explain or describe in further detail: *

Have you or anyone in your household visited or received treatment in a hospital, nursing home, long-term care, or other health care facility in the past 30 days? *

If yes, please explain or describe in further detail: *

Have you or anyone in your household traveled outside New England in the past 21 days? *

If yes, please explain or describe in further detail: *

Have you or anyone in your household cared for an individual who is in quarantine or is a presumptive positive or has tested positive for COVID-19?

If yes, please explain or describe in further detail: *

Do you have any reason to believe you or anyone in your household has been exposed to or acquired COVID-19? *

If yes, please explain or describe in further detail: *

To the best of your knowledge have you been in close proximity to any individual who tested positive for COVID-19? *

If yes, please explain or describe in further detail: *

Disclaimer:

If you answered “yes” to any of the above questions, please send a note to Sarah and Marc explaining the circumstances, ideally prior to entering the office or representing TEG in public. If you learn that you were exposed to COVID or if you experience any symptoms of COVID, we ask that you notify us as soon as possible and that you self-quarantine for a period of two weeks.

General rules for the office:

-Until we notify otherwise, please only come to the office if you have a meeting or project that requires being in-office.
-All other work should be conducted remotely.
-Masks must be worn when moving about the office at all times.
-While sitting at your workstation, you may remove your mask as long as you are the only person in your area (six-foot radius minimum).
-If you are eating/drinking, you may remove your mask but please follow the six-foot distancing guideline and replace your mask as soon as possible.
-Wash your hands for at least 20 seconds with soap and water frequently.
-Avoid handling/touching equipment and workstations that you are not using if at all possible.
-If using a common area, please wipe/disinfect after use.

Have you received the COVID vaccine? *

If yes, when did you receive your vaccine? *