COVID Self-Screening Assessment - STAFF
MANDATORY PRIOR TO ENTRY INTO BUILDINGS.
STAFF: This form should be completed at home prior to traveling to work.
VISITORS: Masks must be worn and hand sanitizer used before and after filling out this form.
Přihlaste se do Googlu, abyste mohli uložit dosavadní postup. Další informace
E‑mail *
First Name *
Last Name *
Phone Number *
Building / Primary Place of Work? *
If Visitor, Destination (Where/Who Visiting)
Have you tested positive for COVID-19 in the past 10 days? *
In your household OR in the community, have you had close contact with someone who has tested positive for COVID-19 in the past 10 days? *
Do you have any of the following symptoms that are NEW, unexplained, or different from your known health conditions: cough, sore throat, difficulty breathing, shortness of breath, fever or chills, muscle aches, runny nose or nasal congestion, fatigue, headache, loss of taste, vomiting or diarrhea? *
In the past 10 days have you traveled outside the US?  (No testing or quarantine needed for domestic travel as of May 1; International travel REQUIRES both if not vaccinated). *
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