Appendix A
Self Screening Checklist
The following form should be distributed to all employees when an Area reaches Pandemic Stage 4 for voluntary, home self screening or Phase 5 for mandatory home, self screening.
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Date __________________
XXXXX Corporation is concerned for your safety and the safety of your co-workers. We are monitoring the development of the influenza pandemic closely. In the interest of ensuring a safe and healthy work environment, we ask that you voluntarily monitor your health status by carefully completing this self-assessment each day before coming to work.
Persons Who Should Complete this Self-Assessment:
1. All active employees daily before coming to work who reside in a state or province with cases of pandemic flu.
2. Employees returning from affected areas within the last ten days.
Do ANY of the following currently apply to you?
Temperature >38 o C/101 o F or higher, AND one or more respiratory symptoms, such as: · Cough · Shortness of breath · Difficulty breathing · Headache · Diarrhea · Muscular stiffness · Loss of appetite · Malaise · Confusion · Rash
If the answer to any of the above is YES and:
· You have developed symptoms of influenza . We are directing you to seek medical attention and remain off the XXXXX Corporation site for 10 days following resolution of symptoms.
· You have not developed symptoms of influenza, We are directing you to remain off the XXXXX Corporation site for 10 days following your last possible exposure to the influenza virus.
If, on the basis of this self-assessment, it is not appropriate for you to enter the XXXXX site , please contact your Manager/Supervisor if you are an employee. Non-employees should communicate with their XXXXX contact. |