COVID-19 STAFF Workplace Screening
If you answer "YES" to any of the symptoms listed in question 1 or "YES" to two or more of the symptoms in questions 2, or your temperature is 100.4 F or higher, please do not go into work. Self-isolate at home and contact your primary care physician's office for direction. You should also:

(1) Isolate (do not leave) at home for a minimum of 10 days since symptoms first appear or per the guidance of your local health department. Call your local health department as a probable COVID-19 or if you test positive.

(2) You must also be 24 hours without fever (without the use of medicine) and improvement in respiratory symptoms.
In the last 14 days, have you developed any of the following symptoms that are new/different/worse from baseline of any chronic illness: *
Required
In the last 14 days, have you developed any of the following symptoms that are new/different/worse from baseline of any chronic illness: *
Required
If you answered YES to any of the symptoms in question 1 or YES to two or more of the symptoms listed in question 2, OR your temperature is 100.4 or higher, please do not go into work. Self-isolate at home and contact your primary care physician's office for direction.
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In the past 14 days, have you had close contact with an individual diagnosed with COVID-19? *
Required
In the past 14 days, have you traveled internationally? *
Required
If you answered YES to either of the above 2 questions, please do not go into work. Self-isolate at home for 14 days and contact your primary care physician's office for direction. If you are given a probable diagnosis or test positive call your local health department to ensure they are aware.
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Your Current Temperature: *
Employee First Name *
Employee Last Name *
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