Second Harvest Food Bank of East Tennessee Screening Questionnaire

As of March 13, 2020

The safety of our employees, clients, families, visitors and volunteers remains Second Harvest Food Bank’s overriding priority. As the COVID-19 (coronavirus) outbreak continues to spread worldwide, Second Harvest Food Bank is monitoring the situation closely and will continue to update protocols and procedures based on recommendations of the national affiliate, Feeding America, the Centers for Disease Control and Prevention (CDC) and the Tennessee Department of Health.

To prevent the spread of COVID-19 and other illnesses, Second Harvest is conducting this simple screening questionnaire. Your participation is important to help us take the proper measures to ensure the health and safety of our employees, clients, families, visitors and volunteers. Thank you for your time, patience and understanding!

Visitor/Volunteer Name: Visitor/Volunteer Phone Number:

Visitor/Volunteer Company or Organization If a visitor, who are you meeting with/purpose of visit:

Visitor/Volunteer Signature:___________________________________________ Date:____________ /2020

Have you returned from any of these countries within the last 14 days? • China • France • Germany • Iran • Italy • Japan • South Korea • Spain Yes________ No________

Have you had close contact with or cared for a person who has been diagnosed with COVID-19 within the last 14 days? Yes________ No________

Have you experienced any cold or flu-like symptoms in the last 14 days? Symptoms include: fever, cough, sore throat, respiratory illness, difficulty breathing. Yes________ No________

Please place a checkmark next to either “yes” or “no.” If the answer is “yes” to any of the following questions, you will be unable to meet with our staff or volunteer at this time:

Note: If you plan to be at the warehouse/in the offices for consecutive days, please alert a staff member if any of your answers above change. The information collected on this form will only be used to determine your access to Second Harvest Food Bank.

FOR STAFF USE ONLY:

Access to facility (circle one): APPROVED DENIED