Marthasville - COVID-19 Screening Form

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Conducting a self-screening is every employee's responsibility. Each morning, please quickly fill out this self assessment. The questions were devised by the health department.

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Today's Date

YYYY

Name *

Are you experiencing any of the following symptoms?

I do not have any symptoms

Fever

Chills

Muscle aches (myalgia)

Runny nose (rhinorrhea)

Sore throat

New olfactory and taste disorder(s)

Headache

Fatigue

Cough (new onset or worsening of chronic cough)

Wheezing

Shortness of breath (dyspnea)

Nausea or vomiting

Abdominal pain

Diarrhea (>3 loose stools/24 hr. period)

Kita:

If symptomatic, list onset date

YYYY

In the past 14 days, have you had any of the following exposures:

No exposure

Household contact with a lab-confirmed COVID-19 case patient

Community-associated contact with a lab-confirmed COVID-19 case patient

Pateikti

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