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FMSHRC COVID-19 SCREENING TOOL

Access to FMSHRC facili�es APPROVED.

Did you answer NO to ALL QUESTIONS? Thank you for helping us protect you and

others during this �me.

Access to FMSHRC facili�es NOT APPROVED. Please see

Did you answer YES to ANY QUESTION? Page 2 for further instruc�ons. Thank you for helping 

us protect you and others during this �me. 

REV20210524

STEP 2. ACCESS REQUEST DETAILS 

OFFICE LOCATION:

1. 2. 3. 4. 5.

__________________________

____________

AUTHORIZER’S NAME:

DATES:

STEP 3. DAILY QUESTIONNAIRE & SIGNATURE 

 TO 

PLEASE SELECT THE

PLEASE READ EACH QUESTION CAREFULLY ANSWER THAT

APPLIES YOU

Within the past 14 days, have you been in close physical contact (6 feet or closer for a

cumula�ve total of 15 minutes) with: 

I. Anyone who is known to have laboratory-confirmed COVID-19?

OR 

II. Anyone who has any symptoms consistent with COVID-19?

Are you isola�ng or quaran�ning because you may have been exposed to a person with 

COVID-19 or are worried that you may be sick with COVID-19? 

Are you currently wai�ng on the results of a COVID-19 test? 

Have you experienced any of the following symptoms in the past 48 hours: 

1. fever of 100.4 F (38 C)

2. cough or chills

3. shortness of breath or difficulty breathing 

4. fa�gue

5. muscle or body aches YES 

6. headache 

7. new loss of taste or smell 

8. sore throat 

9. conges�on or runny nose

10. nausea or vomi�ng

11. diarrhea 

 EMAIL COMPLETED FORM

TODAY’S DATE: ____________

____________ ____________ ____________ ____________

__________________________

6. ____________

EMPLOYEE’S SIGNATURE:____________

By entering my name and submi�ng this form, I affirm that 

I have received my authorizer’s permission to enter the 

workplace on the specific dates listed above, and that I have 

completed the COVID Screening Ques�onnaire.

NO

YES NO

YES NO

YES NO

STEP 1. EMPLOYEE’S NAME 

YOUR FULL NAME: __________________________
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WORKPLACE EXAMPLES

HOW TO USE THIS FORM

On Thursday, an employee has determined he/she has essen�al business that needs to 

be conducted in the office Monday and Tuesday of the following week. 

The same day, the employee should request permission to access the office on those 

dates by checking with the appropriate authorizer outlined in the sec�on below. 

A�er authoriza�on has been granted, the employee will need to enter their name in 

Step 1. and fill out the sec�ons in Step 2. Access Request Details, by 

1. selec�ng the office loca�on from the drop down menu,

2. entering the authorizer’s name, and

3. iden�fying Monday and Tuesday as the desired dates.

On Monday morning, before officially traveling to the office loca�on, the employee will 

need to complete Step 3. Daily Ques�onnaire and Signature, by 

1. answering all four screening ques�ons,

2. signing the form, and

3. selec�ng Email Completed Form.

The form will be automa�cally a�ached to an email message and the email address 

officesafety@fmshrc.gov will appear as the recipient. 

If employee answers YES to any of the ques�ons, he/she should stay home and see 

addi�onal informa�on on page 2 of this form. If he/she answers NO to all the ques�ons 

he/she will be allowed to proceed into the office. 

On Tuesday, the employee should complete the same steps that needed to be completed 

on Monday.

WHO ARE THE AUTHORIZERS

The authorizers will be different for regular employees, supervisors, and department 

heads as follows: 

- regular employees should seek wri�en permission* from their supervisor.

- supervisors should seek wri�en permission* from their department head.

- department heads should seek wri�en permission* from the Execu�ve Director.

*Wri�en permission may be provided by email.
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