COVID-19 Workplace Health Screening

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Are you an Employee, Guest or Student? *

Employee

Guest

Student

Required

First and Last Name *

Section 1: In the last 14 days, have you developed any of the following symptoms that are new/different/worse from baseline of any chronic illness: *

Yes

Subjective fever (felt feverish):

New or worsening cough

Shortness of breath or difficulty breathing

Section 2: In the last 14 days, have you developed any of the following symptoms that are new/different/worse from baseline of any chronic illness: *

Yes

Chills

Headache

Sore throat

Loss of smell or taste

Runny nose or congestion

Muscle aches

Abdominal pain

Fatigue

Nausea

Vommiting

Diarrhea

If you answer YES to any of the symptoms listed in section 1, OR YES to two or more of the symptoms listed in section 2, OR if your temperature is 100.4oF or higher, please do not go into work. Self-isolate at home and contact your primary care physician’s office for direction.

• If your doctor does not recommend COVID testing, consult with your supervisor and follow the guidance from the Managing Communicable Disease in Schools document for return to work criteria.

o If diagnosed as a probable COVID-19 or test positive, call your local health department and make them aware of your diagnosis or testing status.

• You must also have 24 hours without a fever and improvement in symptoms.

In the past 14 days, have you: *

Yes

Had close contact with an individual diagnosed with COVID-19?

Traveled Internationally? (subject to change per State guidance)

COVID Contact *

If you answered yes to having close contact with someone who has a confirmed case of COVID and you are vaccinated you do not have to quarantine.

Required

What is your current temperature *

If you answer YES to either of these questions, please do not go into work. Self-quarantine at home for 14 days. Contact your primary care physician’s office if you have symptoms or have had close contact with an individual for evaluation. If you are given a probable diagnosis or test positive call your local health department to ensure they are aware.

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