Workplace Health Assessment

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Coronavirus Disease (COVID-19)

Name *

Location (check any that apply)

All

Elementary

Maintenance

Transportation

Current Temperature, if your temperature is 100.4 or higher, please do not go into work and contact your supervisor. *

In the past 24 hours, have you experienced any of the following. If you check any of these boxes, please contact your supervisor.

Subjective fever (felt feverish or chills):

New or worsening cough

Shortness of breath

In the past 24 hours have you experienced any of the following. If you check two or more of these boxes, please contact your supervisor.

Sore Throat

Chills

Headache

Loss of taste or smell

Runny nose or congestion

Muscle aches

Abdominal pain

Fatigue

Nausea

Vomiting

Diarrhea

In the past 14 days, have you:

Had close contact with an individual diagnosed with COVID-19

If you answer YES to having close contact with an individual diagnosed with COVID-19, please do not go into work. Self-quarantine at home for 14 days and contact your primary care physician’s office. If you are given a probable diagnosis or test positive call your local health department to ensure they are aware.

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