Mandatory Daily Health Screening Form

As part of MBL’s Reopening Plan and MA State guidance, we ask that each day prior to coming to campus, you review the following questions.   Although this form is not required to be submitted to MBL, we appreciate your diligence on this task for an added level of safety for you as well as members of the MBL community.

1. Have you experienced any of the following symptoms in the past 48 hours?

Cough
Shortness of breath or difficulty breathing
Fever or chills
Fatigue
Muscle or body aches
Headache
Sore throat
New loss of taste or smell
Nausea or vomiting
Congestion or runny nose
Diarrhea

If experiencing ANY of the above symptoms, then report this information to your manager immediately.  These symptoms may be related to COVID-19 and may require you to stay at home and take care of yourself.   If any of these symptoms continue, please contact your primary care doctor. In some cases, it may be necessary to self-quarantine for 14 days and thus you are not permitted to work onsite during that time.  If a doctor confirms that the cause of your symptoms is not COVID-19 related and provides a written release; then you may return to work.

2. Have you recently traveled outside the state of Massachusetts to a state not included in the Commonwealth of Massachusetts COVID-19 lower-risk state exemption list?

Yes

No

If answered YES, you may need to remain out of MBL campus buildings for fourteen (14) days upon returning from travel. Please check with your manager to determine if your travel situation requires you to remain out of campus buildings.

3. Have you recently been exposed to anyone that is experiencing symptoms related to COVID-19 or has tested positive for COVID-19 (within 6 feet of distance or for longer than 10 minutes)?

Yes

No

If answered YES, you must report this information to your manager immediately, and quarantine for the next 14 days, or until the individual experiencing has shown to be negative for COVID-19.

Thank you for your adherence to this daily self-health screening and following the below protocols!

  • maintaining a physical distance of at least six feet whenever possible when I am with others (or at least eight feet when eating or drinking indoors),
  • wearing a face mask at all times, unless enclosed in an office or when outside and able to maintain a safe social distance from others,
  • washing my hands with soap and water frequently for at least 20 seconds, or using alcohol-based hand sanitizer when soap and water is not available, throughout the day and before and after in-person interactions with others, and
  • using disinfecting wipes or spray provided throughout campus and other MBL facilities to clean surfaces with which I come into contact, including but not limited to desks and other working spaces.