COVID-19 Screening - Federal Mediation and Conciliation Service

FEDERAL MEDIATION AND CONCILATION SERVICE COVID-19 SCREENING

PLEASE READ EACH QUESTION CAREFULLY AND CHECK THE ANSWER THAT APPLIES TO YOU	YES/NO
1. Have you experienced any of the following symptoms in the past 48 hours: fever or chills cough shortness of breath or difficulty breathing fatigue muscle or body aches headache new loss of taste or smell sore throat congestion or runny nose nausea or vomiting diarrhea	YES NO
2. Within the past 14 days, have you been in close physical contact (6 feet or closer for a cumulative total of 15 minutes) with: Anyone who is known to have laboratory-confirmed COVID-19? OR Anyone who has any symptoms consistent with COVID-19?	YES NO
3. Are you isolating or quarantining because you may have been exposed to a person with COVID-19 or are worried that you may be sick with COVID-19?	YES NO
4. Have you had a positive COVID-19 test in the past 14 days?	YES NO
5. Are you currently waiting on the results of a COVID-19 test?	YES NO
Access to FMCS Facility is APPROVED. Thank you for helping us protect you and others during this time. Access to FMCS Facility is NOT APPROVED. Please read below for further instructions. Thank you for helping us protect you and others during this time.
I hereby certify that the responses provided above are true and accurate to the best of my knowledge.
Capture:
Approved:

THE SCREENING YOU COMPLETED INDICATES THAT YOU MAY BE AT INCREASED RISK FOR COVID-19

IF YOU ARE NOT FEELING WELL, WE HOPE THAT YOU FEEL BETTER SOON!

Here are instructions for what to do next:


If you are not already at home, please avoid contact with others and go straight home immediately.	Call your primary care provider for further instructions, including information about COVID-19 testing.	Contact your supervisor to discuss options for telework and/or leave.

Before going to a healthcare facility, please call and let them know that you may have an increased risk for COVID-19.

In case of a life-threatening medical emergency, dial 911 immediately!

RETURNING TO THE WORKPLACE

If you have had symptoms consistent with COVID-19 or have tested positive for COVID-19, DO NOT physically return to work until you get a medical evaluation and are approved to return to a work setting by your primary care provider. Please call your supervisor to discuss when to return to work. Read more about when it is safe to be around others at:
https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/end-home-isolation.html

If you have a chronic medical condition that causes COVID-19-like symptoms and you need to access to FMCS within the next few days, please call your supervisor to determine whether you can safely be granted access.

If you have been in close contact with someone with COVID-19, you should stay home and self-quarantine for 14 days before returning to work. Read more about when you should be in isolation or quarantine at:
https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/quarantine.html

If you are currently isolating or quarantining because of concerns about COVID-19 OR you have a COVID-19 test pending, please contact your primary care provider for guidance on when you can return to work. If you have an urgent need to come to FMCS while waiting for a test result or an urgent need to end your quarantine period early, contact your supervisor.

Today's Date:

FEDERAL MEDIATION AND CONCILIATION SERVICE One Independence Square 250 E Street, SW Washington, D.C. 20427