COVID – 19 Virus Daily Screening Form
All employees reporting to a work site or community work program, must completed the following questionnaire and submit it within 1 hour before your shift begins. Submissions will be automatically time stamped when submitted.
(1) Employee ID
(2) Program / Department
(3) Have you traveled to a country or area that has a travel warning of level 2 or 3 as listed by the CDC in the past 14 days? CDC Travel Warnings
(3)(a) If so, where have you traveled?
(3)(b) What was your date of return?
(4) Have you, or anyone in your household, come into close contact (within 6 feet) with someone who has a suspected or confirmed COVID – 19 diagnosis in the past 14 days either at home or on a jobsite, etc.?
(5) Have you had a fever (greater than 100.4 F or 38.0 C) OR symptoms of lower respiratory illness such as cough, shortness of breath, or difficulty breathing in the past 14 days?
(5) Are you currently experiencing a fever (greater than 100.4 F or 38.0 C) OR symptoms of lower respiratory illness such as cough, shortness of breath, or difficulty breathing?
If you have answered ‘Yes’ to any of the COVID-19 related questions, you should notify your Supervisor and leave your work location to seek a medical evaluation.
Never submit passwords through Google Forms.
This form was created inside of St. Charles Youth and Family Services, INC.