The health and safety of our employees, clients, and candidates is paramount to PSI. As the coronavirus disease
2019 (COVID-19) outbreak continues to evolve and spreads globally, PSI is monitoring the
situation closely and will
periodically update company guidance based on current recommendations from the Centers for Disease Control
and Prevention and the World Health Organization. To prevent the spread of COVID-19 and reduce the potential
risk of exposure to our workforce and Candidates, we are implementing the following procedures.
Your participation in completing PSI’s COVID-19 Candidate Questionnaire is mandatory to help us take
precautionary measures to protect you and everyone in the testing center.
Please print & complete this form prior to arriving at the test center, if you are unable to print & complete
prior to your arrival, PSI’s Test Center Administrators will provide at the time of your appointment.
Candidate's Name: Personal Phone Number (mobile/home)
Company/Organization:
1
2
Have you had close contact with or cared for someone diagnosed with
COVID-19 without PPE within the last 14 days?
Yes
No
3
Have you been in close contact with anyone without PPE who has traveled within the last 14 days to one of the
countries listed on https://www.cdc.gov/coronavirus/2019-ncov/travelers/map-and-travel-notices.html
Yes
No
4
Have you experienced any cold
or flu-like symptoms
in
the last 14 d
ays (to include fever, cough, sore throat,
resp
iratory illness, difficulty b
reathing
Have you returned from any of the countries listed as "restricted to travel" within the last 14 days?
https://www.cdc.gov/coronavirus/2019-ncov/travelers/map-and-travel-notices.html
PSI COVID-19 Candidate Questionnaire
5
I understand that PSI requires candidates bring and wear face coverings at all testing facilities. I
have understood that failure to comply by these guidelines or PSI COVID 19 policies & procedures
at the test center will result in denied access to testing.
Yes
No
Candidate Signature _________________________________________ Date: ________________
If you answer "yes" to any of the questions 1-4, you will need to contact Customer Service at
https://www.psionline.com/test-takers/ to see what options are available regarding your
appointment. Please enter your program or test name for program specific support numbers.
If you refuse to answer any of the questions, or if you answer "yes" to questions 1-4, you will not
be permitted to test.
Revised: 06-12-2020
Yes
No
Self-Declaration by Candidate
Yes
No
