Coronavirus Disease (COVID-19) Workplace Screening Form
Please fill out this form before entering the building.
Employee Name (First Last) *
Date *
MM
/
DD
/
YYYY
Time of Entry *
Time
:
Building(s) you are entering for work: *
Required
In the past 24 hours have you experienced: *
Yes
No
Subjective Fever (felt feverish)
New or Worsening Cough
Shortness of Breath
Sore Throat
Diarrhea
Check the box if in the past 14 days have you: *
Yes
No
Traveled via airplane or public transportation internationally or domestically?
Had close contact with an individual diagnosed or suspected of COVID-19?
If you answered YES to any of these questions and/or have a temperature of 100.4 or higher, you may not enter or work on our property until cleared.
Please self-isolate and contact your doctor or health department for further guidance.
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