STEM Academy - Employee COVID-19 Screening Questionnaire

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The safety of our employees is our overriding priority. As the coronavirus (COVID-19) pandemic continues, we are monitoring the situation closely and following the guidance from the Centers for Disease Control and Prevention (CDC) and local health authorities. In order to prevent the spread of the coronavirus and reduce the potential risk of exposure to our workforce, we are asking everyone to complete and submit this questionnaire prior to entering the worksite.

Please read each question carefully and respond to each of the following questions truthfully and to the best of your ability. Your participation is important to help us to take precautionary measures to protect you and our other employees.

Note: The information collected on this form will be maintained as confidential.

Email *

Full Name *

Position *

Work Location *

Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms? (Please take your temperature before you answer this question). *

Fever (100.4º F/37.8ºC or greater as measured by an oral thermometer)

Cough

Shortness of breath or difficulty breathing

Sore throat

New loss of smell and taste

Chills

Headache

Muscle aches

Nausea, diarrhea, or vomiting

None of the above

Required

In the past 14 days, have you been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact? *

Yes

Not to my knowledge

In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19? *

Yes

Not to my knowledge

Have you been tested for COVID-19 and are waiting to receive your test results? *

Yes

Have you tested positive for COVID-19, or are you presumptively positive for COVID-19 based on your health care provider's assessment or your symptoms? Note - If you have tested positive for COVID-19 or have been presumptively positive for COVID-19 based on your health care provider's assessment, please contact Labor Relations and Employment Services when: (1) you have had no fever for at least 72 hours (3 full days), without the use of fever-reducing medication; (2) your symptoms have improved; AND at least 7 days have elapsed since your symptoms first appeared. *

Yes

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