NWFD Member Wellness Survey
This survey is to be completed by employees when coming on and going off of shift. If employees work for 24 hours or longer, survey most be completed every 12 hours. Volunteers should complete this survey after response to an incident
Date of Survey: *
MM
/
DD
/
YYYY
Time of Survey: *
Time
:
Member/ Employee Last Name: *
Your answer
Member/Employee First Name: *
Your answer
Do you have a Cough or Shortness of Breath: *
Do you have a Fever (100.5 F or Greater) or Chills: *
Do you have a Runny/Stuffy Nose or Sore Throat: *
Have you traveled in the last 14 days: *
Have you been exposed to someone with or under investigation for CoVID-19: *
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