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Twinfield- Mandatory Ready to Work COVID-19 Questionnaire Screening
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* Indicates required question
Email
*
Your email
Employee's Name:
*
Your answer
Job Title:
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Your answer
Date
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MM
/
DD
/
YYYY
Was your temperature over 100.0 degrees F before coming to work today?
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No
Yes- If yes, please return home & contact your supervisor
In the last 14 days, have you traveled to any places that required quarantine?
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No
Yes- If yes, please return home & contact your supervisor
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?
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No
Yes- If yes, please return home & contact your supervisor
If you check "Yes" to Question #4, please check all boxes to indicate your current symptoms:
Fever
Cough
Shortness of Breath
Runny Nose
Sore Throat
Chill Body Aches
Fatigue
Headache
Loss of Taste/Smell
Eye Drainage
Congestion
Vomiting
Diarrhea
Other:
Have you been exposed to someone being tested for COVID-19?
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No
Yes- If yes, contact your supervisor to check in about protocols.
Are any members of your household or close contact in quarantine for exposure to COVID-19?
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No
Yes- If yes, please return home & contact your supervisor
**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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Your answer
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