COVID-19 Health Screening

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Employee ID *

Employee Legal Name *

Location *

Please select the location where you are entering.

Have you had any of the CDC-recognized COVID-19 symptoms since your last day at work or the last time you were here? *

Symptoms can include: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, and/or diarrhea.

Yes

Is there anyone in your household who is showing COVID-19 symptoms or who has been diagnosed with COVID-19? *

Yes

Have you been in close contact with anyone exhibiting signs or symptoms of fever, persistent cough, or shortness of breath consistent with COVID-19 who has not been tested or is still awaiting testing? *

Yes

Are you experiencing a loss of taste or smell? *

Yes

If you have answered "yes" to any of the above questions, please contact your direct supervisor and seek testing for COVID-19 immediately.

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Powell County Schools. Report Abuse

Forms