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

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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 November 18, 2020;
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Page background image
A
P
A
S
O
F
CCESS
ROTOCOLS FOR
LL
TATE
FFICES AND
ACILITIES
E
N
18, 2020 (R
)
FFECTIVE
OVEMBER
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 ARE NOT MEANT TO DIAGNOSE COVID-19. THEY ONLY DETERMINE WHETHER
SOMEONE SHOULD BE PERMITTED ENTRY TO A STATE OFFICE OR FACILITY.
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 answer YES to any question on the Screening Questionnaire (see Question 3 for a
special note about quarantined workers with close contact who are approved by Human Resources or
Employee Health to work in critical facilities).
● 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
N
18, 2020 (R
)
FFECTIVE
OVEMBER
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 ARE NOT MEANT TO DIAGNOSE COVID-19. THEY ONLY DETERMINE WHETHER
SOMEONE SHOULD BE PERMITTED ENTRY TO A STATE OFFICE OR FACILITY.
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 answer YES to any question on the Screening Questionnaire (see Question 3 for a
special note about quarantined workers with close contact who are approved by Human Resources or
Employee Health to work in critical facilities).
● 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
IMPORTANT: T
STOP
HE SCREENER SHOULD IMMEDIATELY
THE SCREENING AND DENY ACCESS TO ANY INDIVIDUAL WHO
YES
ANY
(
Q
3,
HR)
ANSWERS
TO
SCREENING QUESTION
EXCEPT FOR CLOSE CONTACT IN
UESTION
IF APPROVED BY
For infection control purposes, I need to ask you a few questions:
1) Do you feel ill today, or have you had ANY of the following NEW
symptoms in the last ten (10) days:
☐ Yes ☐ No
• Fever (either you felt or measured) or chills
• Cough
• Shortness of breath or difficulty breathing
If required by the facility, record screening
• Fatigue
• Unexplained muscle or body aches
temperature: _______________
• Unusual headache
• Loss of taste or smell
(Deny entry if temperature 100.0 or greater)
• Sore throat
• Nasal congestion or runny nose
• Nausea or vomiting
• Diarrhea
2) Have you had a POSITIVE test for COVID-19 infection within the
☐ Yes ☐ No
past ten (10) days, or have you been tested within the past 10 days
because of symptoms and are waiting for the results?
3) Within the last fourteen (14) days, have you:
☐ Yes** ☐ No
Had close contact* with someone diagnosed with or tested for
COVID-19 because of symptoms, or
**Individuals who answer “YES” to close contact
Been told to quarantine by a health care provider or local health
but are allowed entry as essential critical
department because of close contact with someone with
infrastructure workers must be approved by
COVID-19?
Human Resources or 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 answers YES to ANY question on the Screening Questionnaire OR refuses to
participate in the screening process must be denied access to the State office or facility (except for
close contacts in Question 3, if approved by Human Resources or Employee/Occupational Health).
Name of Individual Seeking Access ______________________________________________________ (please print)
Access Determination
Approved
Denied
Name of Staff Completing Form __________________________________ Date:____________ Time: ____________
(Please print)
11/18/2020 (Revised)
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