Respiratory Health Questionnaire

If you answer YES to any of the questions below:

1.   You must obtain a fitness certificate from a health care provider or your company.

    • NOTE: The certificate should clearly indicate, in English, that you are free from any respiratory infectious disease and affirming your fitness to travel for business/work purposes BEFORE you travel to any SNF sites.

2.   If you answer YES to either of the last 2 questions below: Before departing for any SNF sites, you will need to:

A.  Complete a 14 day self-isolation

B.   Obtain a fitness for work certificate from a health care provider or your company

3.   You must submit this form and supporting documents to your employer for submission to SNF contact, who will have it reviewed by SNF Medical personnel.

 


  • Date Format: MM slash DD slash YYYY
  • Name
  • SNF Contact
  • RESPIRATORY HEALTH QUESTIONS

  • YesNo
    Fever
    Cough
    Difficulty Breathing
    Pneumonia
  • YesNo
    Traveled outside the USA
    Been in contact with a person who recently traveled outside the USA to a country where there is an outbreak of COVID-19? https://www.cdc.gov/coronavirus/2019-ncov/travelers/index.html
    Been in contact with a person who became ill after returning from any international travel?
    Been in contact with a person who has undiagnosed respiratory illness or is currently being tested for COVID-19?
    Been in contact with a person who was diagnosed (either via a positive test or clinically determined by a health care professional) to have COVID-19?
  • Only required if you answered YES to any of the above questions.