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Rapid Entry Employee Screening Questionnaire

City of Lincoln, Nebraska

September 21, 2021
Risk Dial Metrics

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City of Lincoln, Nebraska

September 21, 2021
Risk Dial Metrics

COVID-19: Employee Screening Questions

The safety of our employees is our overriding priority. As the coronavirus (COVID-19) pandemic continues, we are monitoring the situation closely and following the guidance from the Centers for Disease Control and Prevention and local health authorities. In order to prevent the spread of COVID-19 and reduce the potential risk of exposure to our workforce, we are asking everyone to complete and submit this questionnaire prior to entering the worksite. Please do not enter the worksite until your responses have been reviewed and your entry has been approved.

My Unique ID:

If any of your answers to the following questions are "YES" DO NOT report to work and notify your Supervisor for further instructions.

Are you currently experiencing, or have you experienced in the past 72 hours, any of the following symptoms that are not as a result of another condition? (Please take your temperature before you answer this question.)

random text

Yes No	Fever (100.4° F/37.8° C or greater as measured by an oral thermometer)
Yes No	Cough
Yes No	Shortness of breath or difficulty breathing
Yes No	Sore throat
Yes No	New loss of taste or smell
Yes No	Chills
Yes No	Head or muscle aches
Yes No	Nausea, diarrhea, vomiting

In the past 14 days, have you been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact?

Yes No

In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19?

Yes No

Have you been tested for COVID-19 and are waiting to receive test results?

Yes No

Have you tested positive for COVID-19, or are you presumptively positive for COVID-19 based on your health care provider's assessment or your symptoms?

Yes No

NOTE: If you have tested positive for COVID-19 or have been presumptively positive for COVID-19 based on your health care provider's assessment or your symptoms, please contact your Supervisor or People Solutions when: (1) you have had no fever for at least 72 hours (3 full days), without the use of fever-reducing medications; (2) your other symptoms have improved; and at least 7 days have elapsed since your symptoms first appeared.

Is there any reason why you feel you are at higher risk of contracting COVID-19 or experiencing complications from COVID-19 by entering the facility? If "Yes", please provide a brief explanation.

Yes No

Explanation:

Certification

I hereby certify that the responses provided above are true and accurate to the best of my knowledge. By submitting this electronic record to FES, I agree and consent to conduct this transaction involving governmental affairs with FES by electronic means pursuant to the Nebraska Uniform Electronic Transactions Act. I understand that I am not prohibited from refusing to conduct other or future transaction(s) with FES by electronic means.

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