EIS Health Screening Form
In order to protect all employees, all individuals entering our buildings must be screened.

Please complete this form upon your initial entry to the building each day. Your responses will be reported to the appropriate personnel. Please do not report to work if you feel sick or have had a known exposure to COVID-19. If you begin to feel sick throughout your day, notify your supervisor or school nurse.
First Name *
Last Name *
Location/School *
Date *
MM
/
DD
/
YYYY
Time *
Time
:
1. What is your current temperature? *
If temperature is 100.4 degrees or higher (DO NOT COME ON SITE)
2. Do you have a cough, shortness of breath, and/or difficulty breathing? *
If Yes, DO NOT COME ON SITE
Required
3. Do you have two or more of the following symptoms? Fever, chills, repeated shaking with chills, headache, loss of taste or smell, muscle pain (not injury related) or sore throat? *
If Yes, DO NOT COME ON SITE
Required
Please indicate who conducted this screening: *
Please type your initials to confirm that these answers are truthful, to the best of your knowledge. *
If you answered “No” to all questions, you may report to work. If you answered “Yes” to any of the questions, please contact your supervisor for guidance before you report to work along with your primary care provider or other appropriate health-care professional.
Please ensure that your are doing your part to keep everyone safe:

Wash your hands often, for at least 20 seconds, with soap and water.
Maintain a social distance of at least 6 feet between all people at all times.
Avoid touching your eyes, nose, or mouth.
Wear a self-provided cloth mask, especially in situations when social distancing may not be possible.
Do not congregate in parking lots, breakrooms, lobbies, or other common areas.
If you cough or sneeze, cover your mouth in the bend of your elbow or with a tissue
Call the KY COVID-19 Hotline if you have any questions: 1-800-722-5725.
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