EMPLOYEE DAILY COVID-19 SCREENING FORM

COVID-19 SCREENING

Your Name: Required

Date:

IS YOUR TEMPERATURE ABOVE 100.4°F? Yes
No

HAVE YOU HAD ANY KNOWN CONTACT WITH ANYONE WHO HAS TESTED POSITIVE, OR IS BEING TESTED FOR COVID 19? Yes
No

IN THE PAST 30 DAYS, HAVE YOU TRAVELED INTERNATIONALLY OR BEEN IN CONTACT WITH ANYONE WHO HAS? Yes
No

IN THE PAST 30 DAYS, HAVE YOU TRAVELED OUTSIDE YOUR HOME STATE? Yes
No

NON-PRODUCTIVE (DRY) COUGH? Yes
No

FEVER? Yes
No

RESPIRATORY DISTRESS? Yes
No

I CERTIFY THAT THE ASWERS TO THESE QUESTIONS ARE TRUE Yes
No