Coronavirus Disease (COVID-19)    
GPS Workplace Health Screening
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Building Name *
Employee Name *
Date *
MM
/
DD
/
YYYY
Time In *
Time
:
In the past 24 hours, have you experienced: *
Yes
No
Subjective fever (felt feverish):
New or worsening cough:
Shortness of breath:
Sore throat:
Diarrhea:
Current temperature *
If you answered "yes" to any of the symptoms listed above, or your temperature is 100.4 F or higher, please do not go into work. Self-isolate at home and contact your primary care physician's office for direction.
* You should isolate at home for a minimum of 7 days since symptoms first appear.
* You must also have 3 days without fevers and improvement in respiratory symptoms.
In the past 14 days, have you: *
Yes
No
Had close contact with an individual diagnosed with COVID-19?
Traveled via airplane internationally or domestically?
If you answered "yes" to either of these questions, please do not go into work. Self-quarantine at home for 14 days.
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