Employee Health Screening Tool
Please answer the following questions to determine if it is safe for you to come to the office. Enter your email address for information about this demo.
Email *
What is your employee ID? *
Have you had any signs or symptoms of a fever in the past 24 hours such as chills, sweats, felt "feverish" or had a temperature that is elevated for you (100.04F or greater)? *
1 point
Do you have a cough? *
1 point
Do you have shortness of breath or chest tightness? *
1 point
Do you have a sore throat? *
1 point
Do you have nasal congestion or runny nose? *
1 point
Do you have body aches (myalgia)? *
1 point
Do you have loss of taste and/or smell? *
1 point
Do you have diarrhea? *
1 point
Do you have nausea? *
1 point
Have you vomited in the past few days? *
1 point
Do you have fever, chills or sweats? *
1 point
Have you been in contact within the last 14 days with someone with a confirmed diagnosis of COVID-19? *
1 point
Submit
Never submit passwords through Google Forms.
This form was created inside of Juicyorange, LLC. Report Abuse