Staff / Customer COVID Screening Form
Each Staff Member must be screened by another employee at the start of each shift by answering the questions on the form below.

Each Customer and Vendor must be screened by an employee upon entering the facility.

ANYONE will be denied entry and/or required to immediately leave the building:
- who has a temperature above 100.0, or
- who answers "YES" to any ONE of the "Yes/No" questions below, or
- who exhibits any symptoms that might be consistent with the symptoms of COVID-19, or
- who refuses to cooperate with the screening process and/or follow our policies.


Please contact management with any questions.

(Version 3, updated 12/13/20)
Your First and Last Name *
Your Cell Phone # [REQUIRED IF NOT ON FILE!]
If your current temperature as measured by no-touch thermometer greater than 100.0 degrees, please record below. (Not allowed on the premises!)
Have you OR A MEMBER OF YOUR HOUSEHOLD OR A HOUSE GUEST been in close contact with a confirmed OR SUSPECTED case of COVID-19 within the last 2 weeks? [If "YES", may not enter.] *
Restricted & Lower Risk States as of 11/27/20
Have you OR A MEMBER OF YOUR HOUSEHOLD OR A HOUSE GUEST travelled to Mass. from one of the restricted states above within the last 2 weeks? [If "YES", may not enter unless you / your household member / guest has had a negative COVID-19 test within 72 hours of entering the state, OR after having entered the state.] *
Have you recently experienced ANY of the following within the last 48 hours: cough, shortness of breath, sore throat, loss of taste or smell, vomiting, or diarrhea? [If "YES", may not enter.] *
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