"Screening Questionnaire for State Operated Offices & Facilities" - Maryland

Screening Questionnaire for State Operated Offices & Facilities is a legal document that was released by the Maryland Department of Budget and Management - a government authority operating within Maryland.

Form Details:

  • Released on April 19, 2021;
  • The latest edition currently provided by the Maryland Department of Budget and Management;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Maryland Department of Budget and Management.

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Rate (4.4 / 5) 27 votes
A
P
A
S
O
F
CCESS
ROTOCOLS FOR
LL
TATE
FFICES AND
ACILITIES
E
A
19, 2021 (R
)
FFECTIVE
PRIL
EVISED
These protocols may be amended as needed in response to rapidly changing circumstances related to COVID-
19 infection.
Building entry protocol must be put into place in every State agency to protect employees, visitors, and
those in the care and custody of the State. ALL individuals entering ALL State-operated buildings must
be ASKED Screening Questions.
THESE QUESTIONS ONLY DETERMINE WHETHER SOMEONE SHOULD BE PERMITTED ENTRY TO A
STATE OFFICE OR FACILITY. THEY ARE NOT MEANT TO DIAGNOSE COVID-19.
The Screening Questionnaire script must be followed. The Screening Questionnaire should NOT be handed to
individuals to complete. The questions must be asked, and the screener must attempt to maintain a distance of
6 feet while asking the questions. See attached.
Access to State Office Buildings and Facilities
● Entry screening staff MUST be present at all entrances.
● Access will be controlled.
● Prior to entry all individuals (staff, visitors, vendors, contractors, etc.) must be ASKED the screening
questions by entry screening staff.
● Individuals who refuse to participate in the screening process must be denied access to the State
office or facility.
● Refusal by an employee to answer screening questions may result in the employee being placed on
unauthorized leave without pay and may result in the imposition of disciplinary action.
A
P
A
S
O
F
CCESS
ROTOCOLS FOR
LL
TATE
FFICES AND
ACILITIES
E
A
19, 2021 (R
)
FFECTIVE
PRIL
EVISED
These protocols may be amended as needed in response to rapidly changing circumstances related to COVID-
19 infection.
Building entry protocol must be put into place in every State agency to protect employees, visitors, and
those in the care and custody of the State. ALL individuals entering ALL State-operated buildings must
be ASKED Screening Questions.
THESE QUESTIONS ONLY DETERMINE WHETHER SOMEONE SHOULD BE PERMITTED ENTRY TO A
STATE OFFICE OR FACILITY. THEY ARE NOT MEANT TO DIAGNOSE COVID-19.
The Screening Questionnaire script must be followed. The Screening Questionnaire should NOT be handed to
individuals to complete. The questions must be asked, and the screener must attempt to maintain a distance of
6 feet while asking the questions. See attached.
Access to State Office Buildings and Facilities
● Entry screening staff MUST be present at all entrances.
● Access will be controlled.
● Prior to entry all individuals (staff, visitors, vendors, contractors, etc.) must be ASKED the screening
questions by entry screening staff.
● Individuals who refuse to participate in the screening process must be denied access to the State
office or facility.
● Refusal by an employee to answer screening questions may result in the employee being placed on
unauthorized leave without pay and may result in the imposition of disciplinary action.
S
Q
CREENING
UESTIONNAIRE FOR
S
O
O
& F
TATE
PERATED
FFICES
ACILITIES
1) Do you CURRENTLY have ANY of the following NEW symptoms?
● Fever (either you felt or measured) or chills
● Cough
☐ Yes ☐ No
● Shortness of breath or difficulty breathing
● Fatigue
● Unexplained muscle or body aches
If required by the facility, record screening
● Unusual headache
● Loss of taste or smell
temperature: _______________
● Sore throat
● Nasal congestion or runny nose
(Deny entry if temperature 100.0 or greater)
● Nausea or vomiting
● Diarrhea
2) In the PAST 10 DAYS, have you had any of the following:
● POSITIVE COVID-19 test?
☐ Yes ☐ No
● NEW symptoms of COVID-19 (from above list)?
● NEW symptoms of COVID-19 and a COVID-19 test that is not
back yet?
STOP:
If Yes to Question 1 or Question 2, deny entry. No need to ask any additional questions.
3) Within the last 14 days, have you:
If No, individual may enter.
● Had close contact* with someone diagnosed with or tested for COVID-19
because of symptoms, or
If Yes, proceed to question 4.
● Been told to quarantine by a health care provider or local health
department because of close contact with someone with COVID-19?
4) Are you fully vaccinated?
If No, individual may NOT enter.**
If Yes, individual may enter.
Fully vaccinated means:
● 2 weeks or longer since your second dose in a 2-dose series, such
**Individuals who answer “No” to question 4 but are
as the Pfizer or Moderna vaccine, or
allowed entry as essential critical infrastructure workers
● 2 weeks or longer since you got a single-dose vaccine, such as
may be allowed entry if approved by HR or
Johnson & Johnson’s Janssen vaccine
Employee/Occupational Health.
*Close contact means being within six (6) feet for a total of 15 minutes or more over a 24-hour period (for example, three 5-
minute exposures for a total of 15 minutes).
An individual who refuses to participate in the screening process or refuses to disclose vaccination status must be
denied access to the State office or facility.
Name of Individual Seeking Access __________________________
Access Determination:
Approved
Denied
(please print)
Name of Staff Completing Form _______________________________________ Date:____________ Time: ____________
4/19/2021 (Revised)
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