Test drive our form below
Below is our actual COVID-19 questionnaire. The Logo and QR code are customized for your production. This form was reviewed and cleared by our in-house COVID-19 consultant, attorney and Medical Director. However, we do suggest you have your own legal team review it to assure it meets with your local and corporate regulations.
The fee for this form is based on a per-production-run and per download of data. There are two teirs (1) 50 cast/crew or less (2) 50+ cast/crew. Conatact us for more details.
For an additional fee, you can customize the qustions of this form with your own questions.
As an Employer, HIPAA laws do not apply to you as they do to us. In addition, as the employer, you are legally allowed copies of all answers provided by your employees. We retain these records for one year. A copy of these results are available to you for a nominal fee.
How to use this form
When our form is used in conjunction with a National Set Medic taking temperatures, your scanning time per person is reduced to 10-20 seconds each.
For crews larger than 200 people ask about our infared thermal camers. (Pictured Right)
About this Form
This is NOT a COVID-19 diagnosis tool. It is a Questionnaire from your employer and/or the production company.
The goal of this questionnaire is to determine if your medical signs and symptoms meet the threshold required to entering the worksite. This threshold has been set forth by your employer, the production company and/or local regulations.
This questionnaire is part of a multi-screening health process which may include follow up questions, a temperature check and visual inspection to rule out certain risks.
Your participation in this form and the aforementioned screening process is mandatory for employment. Falsifying any information on this form or during the screening process is grounds for termination.
If you have any concerns or uncertainties with your medical health or the answers you provide DO NOT come to work and contact your medical provider and inform your employer.
Your Answers are stored and protected on a HIPAA compliant server maintained by National Set Medics. Per HIPAA law, your employer is allowed access to these files. Answers are only sent to the employer at the written request of the employer.
If you have any questions or concerns regarding the use of this questionnaire please contact your employer.
DO NOT contact National Set Medics! We do not and cannot answer policy questions on behalf of your employer. Nor can we provide medical advice.
This section is only a small sample of the many rescources available. The information listed below is a courtesy and not intended to be an all-inclusive list. No system, test or protocol will provide a 100% virus-free workplace. You are responsible for your own health education and also responsible for deciding how much “health risk” you are willing to assume to enter this worksite.
Where can I get more information on the Coronavirus COVID-19?
Where can I get a COVID-19 self assessment?
During a pandemic, an ADA-covered employer may take its employees’ temperatures to determine whether they have a fever?
When an employer collects employee temperature functioning as an employer, such as in connection with protecting its workforce during the COVID-19 pandemic, is that information subject to the HIPAA Privacy Rule?
No employers acting as employers are not covered entities or business associates under HIPAA.
But your employer has taken the additional step to contract National Set Medics to provide this form in a HIPAA compliant format.
How can I use this form for my production or worksite? How can I get more information on all the services National Set Medics provide?
You may contact us here: www.nationalsetmedics.com