UB-COVID19 vulnerability questionnaire – Oficina de Seguretat, Salut i Medi Ambient

Detection of personnel particularly vulnerable to SARS-CoV-2 and other possible situations of particular sensitivity.

VERY IMPORTANT: This questionnaire should only be filled in if you are included or included in any of the situations of vulnerability indicated in the Risk Factors section below, and you have not been previously assessed or need updating.

More information: Medical management of vulnerability to COVID-19 in the UB.

Questionnaire

If for any reason you prefer not to answer the questionnaire, please do not do so, contact the medical service at medicinadeltreball.ossma@ub.edu to inform us.

Fields marked with an asterisk (*) are mandatory

Personal data

Surnames, Name*

Date of birth*

NIF*

Relationship with the UB*PTGASPDI

Faculty/Center*

Department/service/unit*

Building/s

E-mail*

Risk factors

Do you have any of the following risk factors?
(With the Crtl. key you can select several options)

Age

If you have checked any of the above boxes, except for pregnancy or being over 60 years old, please explain:

How long have you been suffering from this?

What is the medical diagnosis for this risk factor?

What is your current medical treatment?

Do you consider that your pathology is under control?
If you consider it necessary, you can attach updated medical information
(Maximum size of the file: 20Mb)

Other diseases

Do you have any other disease that is not on the list for which you need treatment and that you think could be incompatible with working conditions at the current time of the pandemic?* YesNo

If yes, if you wish, tell us your diagnosis, treatment, and current health status, and we will evaluate it

Disabilities

Do you have any disability that you consider incompatible with your working conditions at the UB?*YesNo

If yes, please explain your personal situation and we will evaluate it

Data about your current UB face-to-face activity

What means of transportation do you use to get to your place of work?

How long will it take you to get to your work place?

What means of transport did you use before the pandemic situation?

What is your usual place of work?

Your tasks at this moment are different from the usual ones and therefore, in your opinion, the activity presents some risk (other than SARS-CoV2)

Habitual schedule of your work place

Schedule predicted and days of presence/presential work at the moment

In case of PDI, weekly hours of face-to-face teaching planned, both theoretical and practical

Do you have to access another work place different from your usual one during your stay at the UB?*SíNo

Where? Why?

Do you use any equipment, furniture, material that is also used by other colleagues or employees and may represent a risk of contamination?

Is there a cleaning service for the furniture and facilities you use?*YesNo

In case you make an additional cleaning of the furniture or materials you use, do you have the appropriate products and protection elements? What are these?

If you are alone, do you have regular contact (telephone? face-to-face?) with someone during the time you are at your workplace in case you have to communicate an emergency situation?*YesNo

With whom?

Interaction with other people

Do you consider that your job requires at some point to have a close contact at your place of work? (*Close contact = any person who has been in the same place as the case at a distance of less than 2 meters for at least 15 minutes without adequate protection)
YesNo

Explain the situation

Tasks

Indicate briefly what are the tasks that you will perform at your usual place of work (on-site and telecommuting) and that have led you to think that, being vulnerable, they represent a risk to your health

Signature

I declare that*:

the information I have provided in this questionnaire is true

I will inform the OSSMA in case of any modification of my situation

Signature of the worker*
(Draw your signature in the box)

IMPORTANT:

Since the questionnaire contains medical information, it will be sent directly and only to health personnel at medicinadeltreball.ossma@ub.edu. From this address, only technical information will be forwarded to the prevention technicians. Based on the answers to the questionnaire, a medical and technical assessment will be made to determine if there is any specific condition to be considered.

Right to information regarding the processing of personal data

(1) The responsible for the processing of your data is the General Secretary of the University of Barcelona. (2) The purpose of the processing is to manage the periodic monitoring of the health status of employees. (3) You have the right to access your data, rectify them, delete them, oppose their processing, request portability and the limitation of processing, in certain circumstances. (4) You can consult the detailed information on the above-mentioned treatments.

I declare that I have read the right to information and I consent to the processing of my personal data in the terms indicated.

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