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?
MM
/
DD
/
YYYY
(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.
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