STAR Center Full Time Staff Health Screen Questionnaire

STAR Center Full Time Staff Health Screen Questionnaire

Revised 19 March 2021

This form should be submitted within 24 hours before your planned arrival on campus

The Board of Trustees require all employees/visitors coming to AMO Plans campus to complete this questionnaire truthfully to ensure their wellbeing as well as those working at AMO Plans and in order to maintain the essential functions of the organization.

It should be noted that as of the above noted revision date, Broward County's COVID-19 restrictions remain in effect. Additionally, the State of Florida has travel restrictions for those arriving from certain locations in the United States to the State of Florida. We will follow-up with you if/as necessary to advise of any protocols that may be required.The priority of AMO Plans and STAR Center is to preserve the health of our Plans Participants and employees. Authorization MUST be received from HR before access to the campus is allowed.

* = required field

YOUR NAME YOUR NAME First Last
YOUR PRIMARY PHONE NUMBER YOUR PRIMARY PHONE NUMBER - ### - ### ####
YOUR EMAIL ADDRESS

Confirm Email Address

Your email address that replies to this questionnaire will be sent to.
Address / Location that you will be leaving from immediately prior to traveling to AMO Plans Campus. Address / Location that you will be leaving from immediately prior to traveling to AMO Plans Campus.
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Last day worked at AMOPLANS: Last day worked at AMOPLANS: / MM / DD YYYY
Planned return date to AMOPLANS: Planned return date to AMOPLANS: / MM / DD YYYY
Number of days away:
1. HAVE YOU TRAVELED OUTSIDE THE TRI-COUNTY AREA (BROWARD, MIAMI-DADE AND PALM BEACH) IN THE PAST 10 DAYS, EXCEPT TO/FROM TRAVEL TO YOUR HOME OF RECORD.

1. HAVE YOU TRAVELED OUTSIDE THE TRI-COUNTY AREA (BROWARD, MIAMI-DADE AND PALM BEACH) IN THE PAST 10 DAYS, EXCEPT TO/FROM TRAVEL TO YOUR HOME OF RECORD. Yes No

This includes travel outside tri-county area (Broward, Miami-Dade and Palm Beach), as well as to other States within continental United States.
1a. If YES, please provide the following:
1. Mode of Transportation (Car/Air etc.)
2. Have you been in a group size of more than 10 people (excluding grocery stores, pharmacies or similar setting)
3. Town(s)/City/Cities visited
4. County/Counties visited (if known)
5. State(s) visited
6. Date(s) of visit(s)
2. ARE YOU CURRENTLY EXPERIENCING - OR HAVE YOU EXPERIENCED IN THE PAST 72 HOURS - ANY OF THE FOLLOWING SYMPTOMS?

a. FEVER (100.4F / 38C using an oral thermometer)
b. CHILLS
c. COUGH
d. SORE THROAT
e. SHORTNESS OF BREATH
f. BODY ACHES
g. LOSS OF SENSE OF SMELL
h. LOSS OF SENSE OF TASTE

2. ARE YOU CURRENTLY EXPERIENCING - OR HAVE YOU EXPERIENCED IN THE PAST 72 HOURS - ANY OF THE FOLLOWING SYMPTOMS?

a. FEVER (100.4F / 38C using an oral thermometer)
b. CHILLS
c. COUGH
d. SORE THROAT
e. SHORTNESS OF BREATH
f. BODY ACHES
g. LOSS OF SENSE OF SMELL
h. LOSS OF SENSE OF TASTE Yes No
2a. Please provide details to explain why you have answered YES to question 2.
3. HAVE YOU BEEN IN A GROUP OF MORE THAN 10 PEOPLE OR HAD CLOSE PERSONAL CONTACT, AS DEFINED BELOW, WITH ANYONE WHO IS EXPERIENCING THE SAME SYMPTOMS AS 2A. to 2H. ABOVE IN LAST 10 DAYS?

a. Within 6 feet for more than 15 minutes
b. In a confined space (cab, small room, shared stateroom, berthing proximity, office etc.)

3. HAVE YOU BEEN IN A GROUP OF MORE THAN 10 PEOPLE OR HAD CLOSE PERSONAL CONTACT, AS DEFINED BELOW, WITH ANYONE WHO IS EXPERIENCING THE SAME SYMPTOMS AS 2A. to 2H. ABOVE IN LAST 10 DAYS?

a. Within 6 feet for more than 15 minutes
b. In a confined space (cab, small room, shared stateroom, berthing proximity, office etc.) Yes No

The 10 days refers to your Planned or Actual date of arrival on AMO Plans campus as given above.
3a. Please give details explaining why you answered YES to question 3
4. HAVE YOU VISITED ANY MEDICAL FACILITY (INCLUDING IN-PATIENT HOSPITAL CARE, EMERGENCY TREATMENT OR PROCEDURE AT A HOSPITAL, URGENT CARE FACILITY OR OUTPATIENT FACILITY) IN THE LAST 10 DAYS?

4. HAVE YOU VISITED ANY MEDICAL FACILITY (INCLUDING IN-PATIENT HOSPITAL CARE, EMERGENCY TREATMENT OR PROCEDURE AT A HOSPITAL, URGENT CARE FACILITY OR OUTPATIENT FACILITY) IN THE LAST 10 DAYS? Yes No

The 10 days refers to your Planned or Actual date of arrival on campus as given above.
4a. If you have visited a medical facility in the last 10 days, what was the location of the facility and what was the reason for the visit?
5. HAVE YOU BEEN CARING FOR SOMEONE AT HOME OR BEEN IN CONTACT WITH ANYONE WHO HAS CONTRACTED OR DISPLAYED SYMPTOMS CONSISTENT WITH COVID-19?

5. HAVE YOU BEEN CARING FOR SOMEONE AT HOME OR BEEN IN CONTACT WITH ANYONE WHO HAS CONTRACTED OR DISPLAYED SYMPTOMS CONSISTENT WITH COVID-19? Yes No
5a. Please give details if you have answered YES to question 5.
6. HAVE YOU EVER BEEN SCREENED, DIAGNOSED OR TESTED FOR THE NOVEL CORONAVIRUS (COVID-19), INCLUDING HERE AT AMO PLANS CLINIC?

6. HAVE YOU EVER BEEN SCREENED, DIAGNOSED OR TESTED FOR THE NOVEL CORONAVIRUS (COVID-19), INCLUDING HERE AT AMO PLANS CLINIC? Yes No
6a. Please provide the following information - and any other relevant details - if you have answered YES to question 6:
a. Where tested?
b. Date of positive test?
c. Date of first negative test?
d. Date of second negative test?
e. Other relevant information if applicable.

*NOTE: If you have tested positive, 2 consecutive negative tests, 5-days apart, are required.
Covid-19 Vaccines

All AMO Plans / STAR Center COVID-19 protocols remain in place and no immediate relaxation is planned, regardless of whether you have been vaccinated for COVID-19. However, in anticipation of future change, we require the following information.
7. Have you been vaccinated against COVID-19?

7. Have you been vaccinated against COVID-19? Yes, I have been vaccinated. No, I have not been vaccinated.
8. Was it 1 or 2 dose vaccines?

8. Was it 1 or 2 dose vaccines? 1-dose vaccine 2-dose vaccine
8a. Name of 1-dose vaccine?

8a. Name of 1-dose vaccine? Johnson & Johnson/Jannsen Oxord Astra-Zeneca Other Other

Please pick one or add other(s)
8b. Date of your 1-dose vaccine? 8b. Date of your 1-dose vaccine? / MM / DD YYYY
8a. Name of your 2-dose vaccine?

8a. Name of your 2-dose vaccine? Pfizer BioNTech Moderna Other Other

Please select one or add other(s)
8b. Date of 1st vaccine dose? 8b. Date of 1st vaccine dose? / MM / DD YYYY

Please select a date.
8c. Date of 2nd vaccine dose? 8c. Date of 2nd vaccine dose? / MM / DD YYYY

Please select a date.
This form should be submitted within 24 hours before your planned arrival on campus