COVID-19 Employee Questionnaire
Please fill out this form daily prior to 8:30AM
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Name *
Date *
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Building *
Are you experiencing chills, repeated shaking with chills, sweating? *
Are you experiencing ANY of the following symptoms? Cough, Shortness of Breath, Difficulty Breathing, New Loss of Smell, New Loss of Taste *
Are you experiencing TWO OR MORE of the following symptoms? Fever (measured or subjective) ,Chills Rigors (shivers), Myalgia (muscle aches), Headache, Sore Throat, Nausea or Vomiting, Diarrhea, Fatigue Congestion or runny nose *
Do you have a temperature over 100? *
Have you traveled outside of NJ in the last 14 days to a state on the quarantine list? *
In the past two weeks have you been in contact with someone diagnosed with COVID-19? *
In the past two weeks have you been in contact with someone with COVID-19 symptoms? *
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