ODOC Form 22 B
Page 1 of 4
Effective 6/23/2020 for DOE 20/DHS 19
FORM 22B: OK WAP Pandemic Pre-Screen Client Questionnaire
Client Name: _______________________________Date of contact: _________________, 2020
Job Number (if applicable): ___________________________
Address: __________________________________________
The person listed above certifies that, to the best of his or her knowledge, neither they, nor a
member of their household, nor a person with whom they are in close contact:
1. Has experienced any cold or flu-like symptoms in the previous 14 days (fever, cough,
sore throat, respiratory illness, difficulty breathing).
a. Yes
b. No
2. Is currently diagnosed with COVID-19.
a. Yes
b. No
3. Has a test pending for COVID-19.
a. Yes
b. No
4. Is currently under quarantine due to COVID-19 concerns.
a. Yes (document client's quarantine timeline on page 3)
b. No
5. Has had contact in the previous 14 days with someone diagnosed with COVID-19.
a. Yes
b. No
6. Has traveled in the previous 14 days to any location designated by the Centers for
Disease Control as “having widespread ongoing transmission with restrictions on entry
to the United States” and/or subject to a Level 3 travel health global pandemic notice.
a. Yes
b. No
If any of the above are answered YES, a deferral will be advised for 30 days.
Date of Deferral: __________________, 2020
Follow-up: _______________________, 2020
See further guidance on second page.
ODOC Form 22 B
Page 2 of 4
Effective 6/23/2020 for DOE 20/DHS 19
If the questions from Page 1 are all answered NO by the client, then the following questions
need to be asked to insure the safety of both WAP staff and clients:
1. Will you be willing to vacate the WAP work area during WAP work (another room with a
door or plastic wall, or outside), AND, only the homeowner/client can be present (this
cannot be a minor)? (Take into consideration some families cannot find childcare)
2. Will you be willing to wear a face covering (while in the same room/area as WAP staff)
during the WAP work?
3. Will you be willing to sign a COVID-19 Hold Harmless Agreement? See Page 4.
Based on the answers provided by the client, the WAP staff member conducting the interview
must make a decision whether WAP work can proceed or the home needs to be deferred.
If any of the questions from page one are unanswered or uncertain, it is up to the WAP staff
member conducting the interview to make a decision about deferral. If the questions cannot be
answered, and the risk of exposure cannot be determined, the home may need to be deferred
for 30 days.
Provide the client with any educational resources during this time and upon first arrival to the
home. Educate the client on what safety practices we are implementing and any other
pandemic related education.
Any remarks, clarification, or documentation provided by the WAP staff member, needs to be
added to this document on the last page. Any additional client check-ins are documented here.
Keep a copy of this questionnaire in the client file and provide a copy to the client upon
completion of the home.
This questionnaire was conducted on the following date: ________________________, 2020
WAP Staff Name
WAP Staff Signature
ODOC Form 22 B
Page 3 of 4
Effective 6/23/2020 for DOE 20/DHS 19
Additional remarks, clarification, or documentation:
ODOC Form 22 B
Page 4 of 4
Effective 6/23/2020 for DOE 20/DHS 19
__________________________________________ ____________________
Pandemic (COVID-19) Hold Harmless Agreement
I, , have read the above pages 1-3 and, to the best of my
knowledge, certify the above answers are correct. I understand that personal contact with others,
including, but not limited to, Weatherization employees or subcontractors during this COVID-19
pandemic involves a certain degree of risk.
After carefully considering the risks involved, I agree, to the extent allowable by law, to hold harmless,
, weatherization employees,
subcontractors, ODOC, its agents, officers and employees from any loss or injury sustained either
directly or indirectly as a result of exposure to COVID-19 and shall indemnify ODOC of the same from
any claims made by third parties.
Client Signature Date