Staff Daily Self-check Form
To be completed each day before coming into buildings
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Your Name *
Please include the name of your agency as well, if you are not an employee of FASD
Your Email Address *
Your Title or Department *
Please review the list of symptoms below and then answer Yes or No to the following question.
**GROUP A**
●  Temperature of 100° F or above*
●  Cough
●  Shortness of breath or difficulty breathing
●  Loss of smell or taste

**GROUP B**
●  Chills
●  Rigors
●  Muscle aches
●  Headache
●  Sore throat
●  Nausea or vomiting, or diarrhea
●  Fatigue
●  Congestion or runny nose

*Note that employees must be fever-free WITHOUT the use of fever-reducing medications.

Do you have one (1) or more symptoms listed above under Group A, OR do you have two (2) or more symptoms listed above under Group B? *
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:

►  STEP 1:  Contact your direct Supervisor immediately to review your circumstances.  Do so prior to attempting to enter any building.  

►  STEP 2:  Based on your case review, it may be determined that you must self-isolate at home or be tested and/or seek a return to work note/script from your physician that you are being treated for another condition, or report to work as normal.  

In any case, if you start feeling sick while at work, immediately remove yourself from the premises and follow Steps 1 and 2 above.



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