Form 2 screening questionnaire

2/1/22, 10:31 AM

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NIH Clinical Center Screening Questionnaire

OMB#: 0925-0771 Expiration date: 03/31/2022
Public reporting burden for this collection of information is estimated to average 5 minute per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining
the data needed, and completing and reviewing the collection of information. An Agency may not
conduct or sponsor, and a person is not required to respond to, a collection of information unless it
displays a current valid OMB control number. Send comments regarding this burden estimate or any
other aspect of this collection of information, including suggestions for reducing this burden, to NIH,
Project clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (09250771). Do not return the completed form to this address.

In order to enter the NIH Clinical Center (Building 10), please answer the following questions. Share your
results with the staff member at the Building 10 (NIH Clinical Center) entrance. We will not store or share
your data.
In the past 48 hours, have you had a fever?
Yes

No

In the past 48 hours, have you had a cough, shortness of breath, or difficulty breathing that is new or
getting worse?
Yes

No

In the past 48 hours, have you had any of these symptoms?

-New loss of taste or smell

-Nausea, vomiting, or diarrhea

-Muscle or body aches

-Headache

-Sore throat
Yes

No

Do you currently have a runny nose or congestion that is NEW?

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-Nausea, vomiting, or diarrhea

-Muscle or body aches

-Headache

-Sore throat
Yes

No

Do you currently have a runny nose or congestion that is NEW?
Yes

No

In the past 20 days, have you tested positive for COVID-19?
Yes

No

In the past 20 days, has anyone in your household tested positive for COVID-19?
Yes

No

In the past 10 days, have you been advised by a public health or medical official to self-quarantine at this
time because of exposure to someone with COVID-19?
Yes

No

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OK to Proceed
Valid for: Tuesday, 02/01/2022 10:33 AM
Please show this screen to the staff member at the NIH
Clinical Center (Building 10) entrance.

Thank you for helping us protect you and others during
this time.

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