Daily Mandatory Health Screening Assessment

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This mandatory assessment must be completed daily prior to beginning work. If you suspect or have answered YES to any of the below questions, do not come to work, please call Human Resources.

Name *

Date *

YYYY

Did you have a high temperature before coming into work today? *

Yes

Did you have any COVID-19 symptoms before coming into work today? *

https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html

Yes

Have you had any COVID-19 symptoms within the past 14 days? *

Yes

Have you tested positive for COVID-19 within 14 days? *

Yes

Have you had close contact with a confirmed or suspected COVID-19 case within the past 14 days? *

Yes

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