DAILY Staff Covid Questionnaire
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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
Have you tested positive for COVID-19 in the past 10 days? *
Are you currently awaiting results from a COVID-19 test? *
Have you been diagnosed with COVID-19 by a licensed healthcareprovider (for example, a doctor, nurse, pharmacist, or other) in thepast 10 days? *
Have you been told that you are suspected to have COVID-19 by alicensed healthcare provider in the past 10 days? *
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. *
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. *
Required
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