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Blackbird and Shay COVID-19 Workplace Health Screening
All staff must complete this form prior to coming into the building to which you are reporting to.
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* Indicates required question
Name:
*
Your answer
Date of Access to Building
*
MM
/
DD
/
YYYY
In past 24 hours, have you experienced:
Fever/Felt Feverish?
New Cough?
Worsening Cough?
Shortness of Breath?
Sore throat?
Vomiting/Diarrhea?
What is your current temperature?
*
Your answer
If you answered "yes" to any of the above, or your temperature is 100.4 F or higher, please do not go into work. Self-isolate at home and contact your primary care physician's office for direction. Please notify your supervisor.
Have you had close contact in the last 14 days with an individual diagnosed with COVID-19?
*
Yes
No
Have you engaged in any activity or travel within the last 14 days to high risk COVID-19 areas with uncontrolled or significant spread?
*
Yes
No
Have you been directed or told by the local health department or your healthcare provider to self-isolate or self-quarantine?
*
Yes
No
If you answer “yes” to either of these questions, please do not go into work. Self-quarantine at home for 14 days.
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