Coronavirus Disease (COVID-19) Workplace Screening Form
Please fill out this form before entering the building. Updated: 1/5/2021
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Employee Name (First Last) *
Date *
MM
/
DD
/
YYYY
Time in *
Time
:
Building(s) you are entering for work: *
Required
1.. In the last 14 days, have you developed any of the following symptoms that are new/different/worse from the baseline of any chronic illness: *
Yes
No
Subjective Fever (felt feverish)
New or Worsening Cough
Shortness of breath or difficulty breathing:
2.. In the last 14 days, have you developed any of the two following symptoms that are new/different/worse from the baseline of any chronic illness: *
Yes
No
Chills:
Headache:
Sore throat:
Loss of smell or taste:
Muscle aches:
Vomiting:
Diarrhea:
Current Temperature *
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 your temperature is 100.4°F or higher, please do not go into work. Self-isolate at home and contact your primary care physician's office for direction.
You should isolate at home until you are fever free for at least 24 hours, your symptoms are improving, and it has been at least 10 days since symptoms first appeared or per guidance of your local health department or healthcare provider.

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.
In the past 14 days, have you: *
Yes
No
Had close contact with an individual diagnosed
Have you been told by the health department or your healthcare provider to self- isolate or self-quarantine?
Have you traveled internationally or taken a cruise?
If you answer YES to any 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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