SALS Employee Daily COVID Questionnaire
All employees who will be in the building must complete this form every day before they report to SALS for work. Staff who are not scheduled to work in the building should complete the questionnaire and contact the manager on duty to let them know they will be coming into the building.
Please consider the following question, and provide your answers below.
Are any of the following statements true?
▪ I have experienced symptoms of COVID-19 including fever, cough, shortness of breath, or at least two of the following symptoms: fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell in the past 14 days, OR
▪ I have tested positive for COVID-19 in the past 14 days, OR
▪ I have knowingly been in close or proximate contact in the past 14 days with someone who has tested positive for COVID-19 or who has or had symptoms of COVID-19.
Note: Answer “yes” if the symptoms you have experienced are of greater intensity or frequency than what you normally experience. Answer “No” if you have been evaluated by a healthcare provider and have been released to return to work or you have had a negative COVID-19 test within 14 days after the onset of symptoms. You must provide either a return to work medical note from your healthcare provider and/or the results of the COVID-19 test to the manager on duty.
If you are able to answer "YES" to one or more of the above statements, select YES below, and call the manager on duty before reporting to the SALS building.
If you are able to answer "No" to all the questions, select NO below.
Based on the above screening questions, I believe that I may present a risk for spreading the COVID-19 virus:
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