COVID-19 Daily Health Screening Form š·
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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https://www.labnol.org/covid19-google-forms-201124
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* Required
Email address
*
Your email
Full Name
*
Your answer
Employee Id
*
Your answer
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.
Your answer
Are you feeling sick?
*
Yes
No
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.
Yes
No
I don't know
Do you have any of the following symptoms?
*
Feeling feverish (such as chills, sweating)
Cough
Mild or moderate difficulty breathing
Sore throat
Muscle aches or body aches
Vomiting or diarrhea
New loss of taste or smell
Congestion or runny nose
None of the above
Electronic Declaration
*
I hereby declare that the details furnished above are true and correct to the best of my knowledge.
Required
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