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Health Screening Questionnaire for Fridley City Hall Employees

2. The safety of our employees, their families, and our residents is the City of Fridley’s highest priority. The Centers for Disease Control and Prevention (CDC) and state/local health authorities have acknowledged community spread of COVID-19 and issued attendant precautions. To reduce the potential risk of exposure to our workforce and city hall visitors, we are conducting a simple screening questionnaire daily. Your participation is important to help us protect you and everyone in the City. Thank you for your time and participation.

   The safety of our employees, their families, and our residents is the City of Fridley’s highest priority. The Centers for Disease Control and Prevention (CDC) and state/local health authorities have acknowledged community spread of COVID-19 and issued attendant precautions. To reduce the potential risk of exposure to our workforce and city hall visitors, we are conducting a simple screening questionnaire daily. Your participation is important to help us protect you and everyone in the City. Thank you for your time and participation.

4. Date*
   Date

5. Employee Name*

6. Department Name*

   Community Development, CSER, City Manager, Finance, Public Safety, Public Works

8. Self-Declaration by Employee
   1) Please select yes or no to indicate if you are experiencing any of the following symptoms, which can be related to COVID-19:

   1) Please select yes or no to indicate if you are experiencing any of the following symptoms, which can be related to COVID-19:

10. • Do you have a fever, or a sense of having a fever? (If you have a temperature at or above 100.4 degrees, you should not report to work)*

    1. No
    2. Yes

12. • Do you have a new cough that you cannot attribute to another health condition?*

    1. No
    2. Yes

14. • Do you have a new or worsening headache that you cannot attribute to another health condition?*

    1. No
    2. Yes

16. • Do you have new shortness of breath that you cannot attribute to another health condition?*

    1. No
    2. Yes

18. • Do you have a new sore throat that you cannot attribute to another health condition?*

    1. No
    2. Yes

20. • Do you have new muscle aches that you that you cannot attribute to another health condition or that may not have been caused by a specific activity (such as physical exercise)?*

    1. No
    2. Yes

22. • Do you have fatigue that you cannot attribute to another health condition?*

    1. No
    2. Yes

24. • Do you have chills, or repeated shaking with chills, that you cannot attribute to another health condition?*

    1. No
    2. Yes

26. • Have you experienced a new loss of taste or smell that you cannot attribute to another health condition?*

    1. No
    2. Yes

28. 2) Have you been in close contact with someone diagnosed with COVID-19 either within 72 hours before their symptoms started, within 7 days after their symptoms began, or within 3 days after their symptoms ended?*

    1. No
    2. Yes
    3. Unknown

30. 3) Have you attended any events or gatherings larger than 10 people within the last 14 days?*

    1. No
    2. Yes

32. 4) Have you experienced a high level of stress related to COVID-19, that is impacting your daily work or personal life?*

    1. No
    2. Yes
    3. I have increased stress, but don’t feel it is impacting my daily work or personal life

34. Have you experienced a high level of anxiety related to COVID-19, that is impacting your daily work or personal life?*

    1. No
    2. Yes
    3. I have increased anxiety, but don’t feel it is impacting my daily work or personal life

36. 6) I have other concerns not addressed above.

38. I agree to abide by the City of Fridley rules and procedures regarding social distancing, handwashing, and use of PPE during the time I am in the workplace.

40. Full Name*

41. Today's Date*

45. As a reminder, you can reduce the spread of COVID-19 and other illnesses by doing the following:

47. • Cover your coughs and sneezes with your elbow or sleeve, or a tissue. Throw the tissue in the trash and wash your hands afterward. • Washing your hands often with soap and water for 20 seconds - especially after going to the bathroom or before eating. If soap and water are not readily available, use an alcohol-based hand sanitizer that contains at least 60% alcohol. • Avoid touching your face – especially your eyes, nose and mouth – with unwashed hands. • Stay home if you have cold or flu-like symptoms, for seven days after your illness onset and three days after your fever resolves without fever-reducing medicine (whichever is longer) and avoid close contact with people who are sick.

    • Cover your coughs and sneezes with your elbow or sleeve, or a tissue. Throw the tissue in the trash and wash your hands afterward. • Washing your hands often with soap and water for 20 seconds - especially after going to the bathroom or before eating. If soap and water are not readily available, use an alcohol-based hand sanitizer that contains at least 60% alcohol. • Avoid touching your face – especially your eyes, nose and mouth – with unwashed hands. • Stay home if you have cold or flu-like symptoms, for seven days after your illness onset and three days after your fever resolves without fever-reducing medicine (whichever is longer) and avoid close contact with people who are sick.

49. Pursuant to the Minnesota’s Government Data Practices Act as well as the Americans with Disabilities Act, the content of this form is non-public data and only to be shared with those working for the city where their position reasonably requires access.

    Pursuant to the Minnesota’s Government Data Practices Act as well as the Americans with Disabilities Act, the content of this form is non-public data and only to be shared with those working for the city where their position reasonably requires access.

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51. 1. Receive an email copy of this form.
52. Email address

    This field is not part of the form submission.

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