Coronavirus Disease (Covid-19) Workplace Health Screening

Name (First and Last) *

Phone number *

*

Yes

No

Have you tested positive for the virus that causes COVID-19 in the last 14 days?

Have you had any of these symptoms in the last 14 days? -> Fever greater that 100 degrees -> Difficulty breathing or shortness of breath -> Cough -> Chills -> Muscle Pain -> Sore throat -> New loss of taste or smell

Are you experiencing fever, difficulty breathing or shortness of breath, a cough, chills, muscle pain, sore throat, or a new loss of taste or smell at this time?

Have you been in close contact with someone displaying these known symptoms of Covid-19?

Have you been in close contact with someone diagnosed with COVID-19 or who has tested positive for the virus that causes COVID-19 in the last 14 days?

Have you traveled to any high-risk locations in the last 14 days?

Yes

No

Have you tested positive for the virus that causes COVID-19 in the last 14 days?

Have you had any of these symptoms in the last 14 days? -> Fever greater that 100 degrees -> Difficulty breathing or shortness of breath -> Cough -> Chills -> Muscle Pain -> Sore throat -> New loss of taste or smell

Are you experiencing fever, difficulty breathing or shortness of breath, a cough, chills, muscle pain, sore throat, or a new loss of taste or smell at this time?

Have you been in close contact with someone displaying these known symptoms of Covid-19?

Have you been in close contact with someone diagnosed with COVID-19 or who has tested positive for the virus that causes COVID-19 in the last 14 days?

Have you traveled to any high-risk locations in the last 14 days?

If you answered “Yes” to any of the questions above, or your temperature is 100.4 or higher, do not proceed into the building or with your planned activity. Return home immediately to self-isolate and contact your primary care physician’s office or nearest urgent care facility for direction. After contacting medical personnel, please contact your immediate supervisor to inform them of the situation. • You should isolate at home for a minimum of 7 days since symptoms first appear. • You must also have 3 days without fevers and improvement in respiratory symptoms.

For questions, please contact Mary Dunsmore at mdunsmore@lansingchristianschool.org