Wellness Check Questionnaire

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Wellness Check Questionnaire - COVID-19

To complete the Wellness Check please answer the following:

In the past 14 days, were you exposed to anyone who was diagnosed with COVID-19 or who experienced COVID-19 symptoms? *

Yes

Are you experiencing a fever today (a temperature of 100.4 degrees Fahrenheit or greater)? *

Yes

Are you experiencing COVID-19 symptoms? Please see a list of some COVID-19 symptoms below: *

Fever (see previous question) or chills

Repeated shaking with chills

Cough

Shortness of breath or difficulty breathing

Fatigue

Muscle or body aches

Headache

Loss of taste or smell

Sore throat

Congestion or runny nose

Nausea or vomiting

Diarrhea

Eye redness with or without discharge

None of the above

Required

If you answered yes to any of the questions above:

1. STOP – do not report to any company facility, field location, or customer site,
2. Contact your supervisor for further instructions, and
3. Complete the Exposure Questionnaire.

Employee *

Date *

YYYY

Supervisor *

Submit

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