pennsylvania

2.

Does the individual have symptoms (i.e., Temperature of 100.4 or higher, cough, shortness of breath, chills, sore throat, headache, fatigue, congestion or runny nose, nausea or vomiting, diarrhea, repeated shaking with chills, muscle pain, new loss of taste or smell or difficulty breathing) that are not attributable to a pre-existing medical condition? Individuals experiencing post-vaccination side effects including chills, tiredness, and headache in the three days after a COVID-19 vaccination do not need to be excluded from the workplace

If the individual has a fever, what is their temperature?

1.

 

Yes

__________ F

3.

Has the individual had clase contact with a person who is confirmed or probable positive for COVID-19? (Close contact: Within six (6) feet for a consecutive total of 15 or more minutes, or the positive case had direct physical contact (hug or kiss), shared eating or drinking utensils, or the positive case spread respiratory droplets directly on them or was showing symptoms (through sneezing or coughing). This includes the 48 hours prior to symptom onset or administration of a positive COVID-19 test.)

Yes

Is the individual awaiting testing results or other diagnostic procedure to determine COVID-19 for any reason other than an impending medical procedure or employer testing?

Yes

Personnel conducting the screening shall notify their supervisor by calling off work. Personnel experiencing symptoms or awaiting results of a diagnostic procedure will need to provide a Return to Work Status Form in order to return to the workplace. Individuals experiencing post-vaccination side effects including chills, tiredness, and headache in the three days after a COVID-19 vaccination do not need to be excluded from the workplace or provide a Return to Work Status Form.

Personnel that do not have a medical provider should contact their local health department or 1-877-PA-HEALTH.

REVISED 2/24/21

COVID-19 Self-Screening Form

Personnel completing the self-screening should ask themselves these questions prior to each shift. Personnel do not need to send this form to a supervisor.

Call us:

(814) 337-4279 

 

FCCA  Administration Office: 

378 Chestnut Street  Meadville, PA 16335

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Family and Community Christian Association