Staff Health Questionnaire

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Staff Health Questionnaire - COVID-19

As an employee of the Stateline Family YMCA, your health and safety are very important to all of us! In an effort to prevent the spread of COVID-19, please review and answer the below health screening questions each day upon arrival.

Full Name *

I have taken my temperature using the provided thermometer and do not currently have a fever greater than 100 degrees Fahrenheit. *

True

False

I do not currently have, nor have I had in the last 72 hours, other potential symptoms of COVID-19: Persistent, dry cough, shortness of breath or difficulty breathing, chills, muscle pain, sore throat, new loss of taste or smell *

True

False

I have not taken medications to lower my temperature in the last 72 hours *

True

False

No one in my household may have or is confirmed to have COVID-19 *

True

False

To my knowledge, no one in my household has been in contact with someone who may have or is confirmed to have COVID-19 *

True

False

I am following recommendations set forth by the CDC and Public Health Departments to prevent the spread of COVID-19 *

True

False

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