Coronavirus COVID-19 Screening Questionare
Email address *
Name: *
Phone Number or Email to reach you at:
In the last 14 days have you traveled outside your normal, daily routine? *
In the last 14 days have you engaged in social distancing while not at work? *
Do you have new or worsening onset of any of the following symptoms: fever, cough, shortness of breath, runny nose, sore throat, chills, body aches, fatigue, headache, loss of taste/smell, eye drainage, congestion? *
If you answered "Yes" to the last questions, please list symptoms below:
Was your temperature 100.4° F or 38° C before coming to work today? *
Have you been exposed to someone being tested for COVID-19 or who has symptoms compatible with COVID-19? *
If you answered "Yes" to any of these questions:
- Please stay home except to get medical care.
- Monitor your symptoms carefully. If your symptoms get worse, call your healthcare provider immediately.
- Get rest and stay hydrated. Take over-the-counter medicines, such as acetaminophen, to help you feel better.
- If you have a medical appointment, notify your healthcare provider ahead of time that you have or may have COVID-19.
- Stay in a specific room and away from other people in your home. If possible, use a separate bathroom. If you must be around others, wear a facemask.
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