Staff Self-Assessment
Health Check-in. Complete every morning!
Today's Date *
MM
/
DD
/
YYYY
Please list your first and last name *
Team *
Temperature *
Have you within the last 14 days been told to quarantine or isolate by a medical provider or health department?
Clear selection
Have you, within the last 14 days, had close contact with someone who has COVID-19?
Clear selection
Have you experienced any of the following symptoms in the past 14 days? If you check any of the following, please contact an administrator. *
Required
Notes or comments:
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