COVID-19 Self Assessment Screening Questionnaire (LG)

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Please take assessment prior to leaving your home if possible.

Name (First and Last) *

Email *

Have you tested positive for COVID-19 in the past 14 days? *

Yes

Required

In the last 48 hours, have you had any of the following new or worsening symptoms of COVID-19, that cannot be attributed to another condition? •Fever • Fatigue • Dry cough • Sore throat • Trouble breathing • shortness of breath • Muscle aches • Loss of smell or taste, or change in taste • Nausea, vomiting or diarrhea • Headache *

Yes

Required

Please take your temperature. Did your temperature read 100.4 or higher? *

Yes

Required

If you answered yes to any of these questions, we ask that you stay home/ return home. Please notify your direct report and let them know you are staying home or going home.

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