Health Screening Form ERA
**This form will be completed during the screening. Please do not hit submit until temperature has been taken and disposition has been verified***
This form must be filled out prior to coming into any program or building.
If any of the symptoms below are reported:
1. Send person home immediately.
2. Increase cleaning in your facility and ensure staff are at least 6 feet apart from one another.
3. Exclude person until they are fever-free (without medication) for 72 hours and 10 days have passed since their first symptom unless they have a clear alternative diagnosis from a medical provider..
4. If multiple employees have symptoms, contact your local health department.
Email address *
Is this screening form for a: *
Your Name: *
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