NJDMAVA COVID-19 Screening Form

At which location are you screening? *

Please select the location that you are screening at. Multiple screenings are not required if switching locations during the work day unless there are changes to your health during that day.

Employment Status *

Contractor
Hourly
State Employee
Visitor

NOTE: If you are a National Guard Member, please use the Federal Employee Option at: https://www.njdmavaevents.org/csf/

Last Name *

First Name *

Middle Initial (If applicable)

Phone *

Todays' Date *

Gender *

Department/Division *

What is your temperature in Fahrenheit as of today? (Use temperature reading at entry to building) *

Please input as seen on the thermometer (ie; 97.9, 98.2, etc.)

1. Have you been diagnosed with COVID-19 and have not yet met the criteria for the discontinuation of isolation per guidance issued by the New Jersey Department of Health and Centers for Disease Control (CDC)? *

YES
NO

If you answer YES to this question, you WILL NOT be allowed to continue into this facility. For EMPLOYEES ONLY: Please contact your immediate supervisor and await contact from Human Resources Division (HRD).

2. Have you been in quarantine or under suspicion for having COVID-19 within the last 14 days? *

YES
NO

If you answer YES to this question, you WILL NOT be allowed to continue into this facility. For EMPLOYEES ONLY: Please contact your immediate supervisor and await contact from Human Resources Division (HRD).

3. In the past 10 days, have you experienced and COVID-19 symptoms (fever 100.4 F), felt feverish, coughing, shortness of breath, difficulty breathing, chills, repeated shaking with chills, muscle/body aches/pains, headache, sore throat, or new loss of taste or smell? *

YES
NO

If you answer YES to this question, you WILL NOT be allowed to continue into this facility. For EMPLOYEES ONLY: Please contact your immediate supervisor and await contact from Human Resources Division (HRD).

4. Have you had an identified exposure to someone with a confirmed diagnosis of COVID-19, someone under investigation for COVID-19, or someone suffering from a respiratory illness within the last 14 days? *

YES
NO

If you answer YES to this question, you WILL NOT be allowed to continue into this facility. For EMPLOYEES ONLY: Please contact your immediate supervisor and await contact from Human Resources Division (HRD).

5. Have you returned from international travel in the last 10 days? *

YES
NO

By signing below, you certify that the information provided is true and correct to the best of your knowledge and belief:

Employee Initials and Last 4 digits of your State ID# | For visitors use initials and last four of Drivers license or government ID. *