Coronavirus Screening Form
Email *
Name *
Contact phone # *
Date of Birth *
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What is your relationship to Hunterdon Healthcare? *
What department do you work in? *
Who is your Director? *
What is your job title? *
Where have you traveled to? *
When did you return from your travel? *
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Anticipated return to work date? *
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DD
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Have you had potential exposure to a confirmed coronavirus case? *
If yes, where was exposure?
If yes, when was exposure?
Do you have a fever greater than 100.4? *
If yes, dates of fever
If yes, temperature
Do you have a cough? *
Do you have shortness of breath? *
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