COVID-19 Daily Health Screening Form 😷
Please do not come to work / school If you have had symptoms consistent with COVID-19, have been exposed or have tested positive for COVID-19.
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Enter your current body temperature in Fahrenheit
Employees should take their temperature before they go to work. If they have a temperature above 100.4F, they should stay home.
Are you feeling sick?
In the last two weeks, did you have close contact with someone with symptoms of COVID-19, tested for COVID-19, or diagnosed with COVID-19?
Close contact is when you are within 6 feet of an infected person for at least 15 minutes.
I don't know
Do you have any of the following symptoms?
Feeling feverish (such as chills, sweating)
Mild or moderate difficulty breathing
Muscle aches or body aches
Vomiting or diarrhea
New loss of taste or smell
Congestion or runny nose
None of the above
I hereby declare that the details furnished above are true and correct to the best of my knowledge.
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