COVID-19 Employee Screening Tool

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This form is to be completed daily by all employees and individuals entering the facility.

Have you been within 6 feet of a person with a lab-confirmed case of COVID-19 for at least 5 minutes, or had direct contact with their mucus or saliva, in the past 14 days? *

Yes

In the last 48 hours, have you had any of the following new symptoms? Check all that apply. *

Fever of 100 F (37.8 C) or above, or possible fever symptoms like alternating chills and sweating

Cough

Trouble breathing, shortness of breath or severe wheezing

Chills or repeated shaking with chills

Muscle aches

Sore throat

Loss of smell or taste, or a change in taste

Nausea, vomiting or diarrhea

Headache

None of the above

Required

Do you have a temperature equal to or greater than 100.0? *

Yes

By signing below I confirm that I have answered the above questions honestly and that I will self-monitor and immediately disclose to my supervisor any signs or symptoms of respiratory infection, including fever, cough, shortness of breath, or sore throat. (Please type your name) *

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