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DAILY Staff Covid Questionnaire
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* Indicates required question
Have you experienced any of the following symptoms of COVID-19 within the last 48 hours?
*
Yes
No
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
Diarrhea
Yes
No
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
Diarrhea
Have you tested positive for COVID-19 in the past 10 days?
*
Yes
No
Are you currently awaiting results from a COVID-19 test?
*
Yes
No
Have you been diagnosed with COVID-19 by a licensed healthcareprovider (for example, a doctor, nurse, pharmacist, or other) in thepast 10 days?
*
Yes
No
Have you been told that you are suspected to have COVID-19 by alicensed healthcare provider in the past 10 days?
*
Yes
No
Daily monitoring for potential COVID-19 symptoms is important to track your current health status. If you experience new symptoms, consider seeing your healthcare provider or getting a test for COVID19, especially where you may have had potential exposures to COVID-19.
By checking the box below, you agree to see your healthcare provider or get a test, as directed above.
*
I agree
Required
You MUST inform your supervisor if you:
• Receive a confirmed positive COVID-19 test result;
• Have been diagnosed with COVID-19 by a licensed healthcare provider;
• Have been told you are suspected to have COVID-19 by a licensed healthcare provider;
• Experience new loss of taste and/or smell with no other explanation; or
• Experience both fever (≥100.4° F) and new unexplained cough associated with shortness of breath
By checking the box below, you agree to notify your supervisor as directed above.
*
I agree
Required
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