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 Health and Safety Supervisor, 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 immediate 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 server maintained by National Set Medics. Although none of the information you provide is considered HIPAA PHI “Personal Health Information” Your infomation is not sent or shared with any other entitiy or person.

If you have any questions or concerns regarding the use of this questionnaire please contact your Health and Safety Supervisor.

DO NOT contact National Set Medics!  We do not and cannot answer policy questions on behalf of your employer.


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.

From https://www.natlawreview.com/article/hipaa-privacy-rule-waiver-other-medical-information-questions-during-covid-19

But your employer has taken the additional step to contract National Set Medics to provide this form as a third party.


How can I use this form for my production or worksite?

Each form is personalized to a job number.  To set up yours now, contact National Set Medics.  This form can be used with or without one of our medics.

How can I get more information on all the services National Set Medics provide?

You may contact us here:  www.nationalsetmedics.com

Email is for identification purposes only.

No personal information will be sent to this email address. We do not share or sell your email or any other information.