ADA-compliant pre-pandemic employee survey

[The following survey can be given to all employees before a pandemic to help employers determine which factors, including chronic medical conditions, might cause employees to miss work in the event of a pandemic.]

Directions : Answer yes to the whole question without specifying the reason or reasons that apply to you. Simply circle yes or no at the bottom.

In the event of a pandemic, would you be unable to come to work because of any of the following reasons:

• If schools or day-care centers were closed, you would need to care for a child;

• If other services were unavailable, you would need to care for other dependents;

• If public transport were sporadic or unavailable, you would be unable to travel to work, and/or

• If you or a member of your household fall into one of the categories identified by the CDC as being at high risk for serious complications from the pandemic influenza virus, you would be advised by public health authorities not to come to work (e.g., pregnant women; persons with compromised immune systems due cancer, HIV, history of organ transplant or other medical conditions; persons less than 65 years of age with underlying chronic conditions; or persons over 65).

Answer:

YES

NO