COVID Self-Screening Assessment - STAFF
MANDATORY PRIOR TO ENTRY INTO BUILDINGS.
STAFF: This form should be completed at home prior to traveling to work.
VISITORS: Masks must be worn and hand sanitizer used before and after filling out this form.
Email address *
First Name *
Last Name *
Phone Number *
Building / Primary Place of Work? *
If Visitor, Destination (Where/Who Visiting)
Have you been diagnosed with COVID-19 in the past 28 days? *
Do you live with someone who has been diagnosed with COVID-19 or is still symptomatic in the past 14 days? *
Do you have any of the following symptoms that are unexplained or different from your known health conditions: *
Yes
No
Fever 100 degrees or higher?
Chills or repeated shaking with chills?
Sore throat?
Difficulty breathing/shortness of breath?
Unexplained muscle aches?
New cough?
New loss of smell or taste?
New runny nose or nasal congestion (different from your normal allergies or seasonal hay fever)?
Vomiting or diarrhea in the last 24 hours?
In the past 14 days have you traveled outside the US or outside Maine, NH, or VT? ***UPDATE 11/16/20: Massachusetts is NO longer exempt.*** *
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