COVID-19 Workplace Health Screening
Based on Shiawassee County Health Department Guidance

DISCLAIMER: This screening tool is subject to change based on the latest information on COVID-19
Name of Building *
Employee Name *
Date *
MM
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DD
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YYYY
Time In *
Time
:
Do you have any of the following symptoms that are new/different/worse from baseline of any chronic illness.
Fever of 100.4 degrees of higher *
New or worsening cough *
Shortness of breath or difficulty breathing - new/different/worse from baseline of any chronic illness *
Chills - new/different/worse from baseline of any chronic illness *
Headache (new onset of severe headache, especially with a fever) *
Sore Throat - new/different/worse from baseline of any chronic illness *
Loss of smell or taste - new/different/worse from baseline of any chronic illness *
Muscle pain - new/different/worse from baseline of any chronic illness *
Had close contact with an individual diagnosed with COVID-19? *
Are you currently awaiting the results of a Covid-19 test?
Clear selection
If you selected "Yes" for any of the above questions, please contact your direct supervisor for further instructions prior to reporting to work.
By submitting this form, you authorize that the information above is correct.
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