Self Assessment Tool
Please Provide the following Information  

Your Employer  
Your First Name  
Your Last Name  
Your Email Address  
Your Office Phone Number  
Your Mobile Phone Number  

In what capacity are you accessing the EDG location?
EDG Employee Number (if applicable)
Which EDG Location will you access?

Have you traveled outside the Continental United States in the past 14 days?

Have you or are you in contact with any individual who travelled  outside the Continental United States in the past 14 days? “Contact” means face to face contact for more than 15 mins or being in the same enclosed space for more than 2 hours.

Have you been in contact with anyone diagnosed with Novel Coronavirus (2019-nCov) or listed as a suspected case in the last 14 days?

Are you experiencing any of the following symptoms: Fever (>38 deg C; > 100.4 deg F), sore throat, shortness of breath or difficulty breathing?


Privacy Notice EDG Inc (EDG) is asking you to provide information about yourself in order to conduct travel and health risk screening for novel coronavirus (2019-nCoV). The categories of information that we are asking for include your name and employer, your telephone and email contact details, the location of your visit to a EDG location, in what capacity you will visit (e.g employee, visitor, contractor), information about recent travel, information about recent contacts and limited health information. This information will not be shared with third parties. You must provide this information in order for us to conduct a risk assessment and determine whether you can access the EDG location. We will also use the information to contact you if necessary in connection with your responses to the screening questions. If you do not provide this information you will not be allowed to access the EDG location. You have the right to review and, if factually inaccurate, to correct the personal data held about you. To exercise these rights, please email Declaration and Consent I declare all my responses to be true and correct to the best of my knowledge. I consent that EDG may collect, use and disclose my personal data, as provided in this form, in accordance to EDG Privacy Policy (accessible at and the above Privacy Notice.