COVID-19 Questionnaire for Examining Assessor

to Complete prior to Performing Assessments

Pl ease respond by checking any box applicable to you and sign below, and provide the completed copy to Di rect IME by fa x or email no less than 24 hours prior
to a s sessment date.

1. If you have tested positive for COVID-19 pl ease indicate which of the following statements a re true, i f a ny:

☐ If you were symptomatic (ha d s ymptoms), you have been in i solation for a t l east 14-days since s ymptoms first began, a nd you have not had
s ymptoms in the past 3 da ys.

☐ If you were asymptomatic (di d not have symptoms), you have been i n isolation for a t least 14-days beginning from the date you were tested and
you ha ve not experienced a ny s ymptoms during this 14-day period.

☐ You have NOT completed a 14-day quarantine. If you check this box, please note the date you were diagnosed with COVID-19 and the date you
fi rs t became symptomatic (if applicable).

Da te first symptomatic: ____/_____/_____ Da te diagnosed with COVID-19: _____/______/______

2. If you have not tested positive for COVID-19, pl ease s elect any of the following that a pply:

☐ Have you travelled i nternationally i n the past 14 days? If so, please note the date of your return a nd the area(s) you visited.

Da te of return from international travel: _____/_____/_____ Areas visited: ________________________________

☐ Have you had close contact (defined as within closer than 6 feet for 10 minutes or more) with someone who wa s diagnosed with or s uspected
to ha ve COVID-19 wi thin the past 14 days? (For example, a family member you live wi th or a co-worker or patient/claimant). If so, please note the
l a st date you had contact with this person and whether the person was actually diagnosed.

Da te of last contact with person: _____/_____/_____ Person actually diagnosed: Yes / No

☐ Have you been mandated to go into quarantine by your phys i cian or a department of health within the past 14 da ys? If so, please explain the
da te the quarantine began a nd the reason for quarantine.

Da te quarantine began: _____/_____/_____ Reason for quarantine: ____________________________________

☐ Have you had the following symptoms wi thi n the past 14 days ? If s o, please note the date you first became s ymptomatic (had s ymptoms) a nd
the l ast date you were s ymptomatic.

 Fever  Decrease or loss of sense of taste or smell

 New onset of cough
 Worsening chronic cough
 Shortness of breath
 Difficulty breathing
 Sore throat
 Difficulty swallowing
 Unexplained fatigue/malaise/muscle aches (myalgias)
 Nausea/vomiting, diarrhea, abdominal pain
 Runny nose/nasal congestion without other known cause
 Pink eye (conjunctivitis)
 Headaches
 Chills

Date first became symptomatic: _____/_____/_____ Date last symptomatic: _____/_____/_____

Name (printed): _____________________________ Signature: ______________________________ Date: _______ / _________/ ________

 COVID-19 Questionnaire for Examining Assessor
to Complete prior to Performing Assessments

Pl ease respond by checking any box applicable to you and sign below, and provide the completed copy to Di rect IME by fa x or email no less than 24 hours prior
to a s sessment date.

1. If you have tested positive for COVID-19 pl ease indicate which of the following statements a re true, i f a ny:

☐ If you were symptomatic (ha d s ymptoms), you have been in i solation for a t l east 14-days since s ymptoms first began, a nd you have not had
s ymptoms in the past 3 da ys.

☐ If you were asymptomatic (di d not have symptoms), you have been i n isolation for a t least 14-days beginning from the date you were tested and
you ha ve not experienced a ny s ymptoms during this 14-day period.

☐ You have NOT completed a 14-day quarantine. If you check this box, please note the date you were diagnosed with COVID-19 and the date you
fi rs t became symptomatic (if applicable).

Da te first symptomatic: ____/_____/_____ Da te diagnosed with COVID-19: _____/______/______

2. If you have not tested positive for COVID-19, pl ease s elect any of the following that a pply:

☐ Have you travelled i nternationally i n the past 14 days? If so, please note the date of your return a nd the area(s) you visited.

Da te of return from international travel: _____/_____/_____ Areas visited: ________________________________

☐ Have you had close contact (defined as within closer than 6 feet for 10 minutes or more) with someone who wa s diagnosed with or s uspected
to ha ve COVID-19 wi thin the past 14 days? (For example, a family member you live wi th or a co-worker or patient/claimant). If so, please note the
l a st date you had contact with this person and whether the person was actually diagnosed.

Da te of last contact with person: _____/_____/_____ Person actually diagnosed: Yes / No

☐ Have you been mandated to go into quarantine by your phys i cian or a department of health within the past 14 da ys? If so, please explain the
da te the quarantine began a nd the reason for quarantine.

Da te quarantine began: _____/_____/_____ Reason for quarantine: ____________________________________

☐ Have you had the following symptoms wi thi n the past 14 days ? If s o, please note the date you first became s ymptomatic (had s ymptoms) a nd
the l ast date you were s ymptomatic.

 Fever  Decrease or loss of sense of taste or smell

 New onset of cough
 Worsening chronic cough
 Shortness of breath
 Difficulty breathing
 Sore throat
 Difficulty swallowing
 Unexplained fatigue/malaise/muscle aches (myalgias)
 Nausea/vomiting, diarrhea, abdominal pain
 Runny nose/nasal congestion without other known cause
 Pink eye (conjunctivitis)
 Headaches
 Chills

Date first became symptomatic: _____/_____/_____ Date last symptomatic: _____/_____/_____

Name (printed): _____________________________ Signature: ______________________________ Date: _______ / _________/ ________