Twinfield- Mandatory Ready to Work COVID-19 Questionnaire Screening
Email address *
Employee's Name: *
Job Title: *
Date *
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Was your temperature over 100.0 degrees F before coming to work today? *
In the last 14 days, have you traveled to any places that required quarantine? *
Do you have new, unusual, 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, vomiting, diarrhea, or congestion? *
If you check "Yes" to Question #4, please check all boxes to indicate your current symptoms:
Have you been exposed to someone being tested for COVID-19 or who has symptoms compatible with COVID-19? *
Are any members of your household or close contact in quarantine for exposure to COVID-19? *
**I understand that I have the responsibility to immediately notify the Principal or Director and my immediate Supervisor should my responses on this questionnaire change. Add your employee signature by typing your name. *
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