Employee Daily Self-check Form
To be completed each day before coming into buildings
Your Name *
Your Email Address *
Your Title or Department *
People with COVID-19 have had a wide range of symptoms reported – ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to the virus. People with one or more of the symptoms on the list below may have COVID-19.

● Temperature of 100.4° F or above

● Muscle aches

● Loss of smell or taste

● Sore throat

● Shortness of breath

● Headache

● Chills

● Nausea or vomiting, diarrhea, or loss of appetite
Are you currently experiencing one or more of the symptoms listed above? *
Have you or anyone you have been in close contact with been diagnosed with COVID-19, or been placed in quarantine for possible contact with COVID-19? *
Have you been asked to self-isolate or quarantine by a medical professional or a local public health official? *
If you replied YES to any of the three questions above, STAY HOME and follow the steps below. DO NOT attempt to go into work.

► Step 1: Call your supervisor to report off/enter an absence in Frontline

► Step 2: Self-isolate at home and contact your primary care physician’s office for direction. That direction, including return to work note/script, should be shared with your direct supervisor before returning.

If you start feeling sick during your shift, immediately remove yourself from the premises, and follow Steps 1 and 2 above.

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