Robert Lewis Magnet Employee Health Screening Form

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This Screening Tool is offered for informational purposes to help you check for COVID-19 symptoms as outlined by the Centers for Disease Control. The guidance you receive depends on the accuracy of the information you provide as well as current guidelines for identifying symptoms associated with COVID-19. Based on your self-reported answers, the tool will provide a response to be used by your employer. Please take the survey and provide the response to your employer according to your employer’s instructions.

This is not a substitute for professional medical advice, diagnosis, or treatment of disease or other conditions, including COVID-19. Always consult a medical professional for serious symptoms or emergencies.

Email *

First and Last Name *

Location *

Today's Date

YYYY

Have you had any signs or symptoms of a fever in the past 24 hours such as chills, sweats, felt "feverish" or had a temperature that is elevated for you/100.4 F or greater? *

Yes

Required

Have you experienced any of the following symptoms? (Check all that apply) *

Chills

New or worsening cough

Shortness of breath of difficulty breathing

Fatigue

New of Unusual Muscle or body aches

New loss of taste or smell

Sore throat

Congestion or runny nose

Nausea or vomiting

Diarrhea

No Symptoms

Required

Have you had prolonged (15 minutes or more without a mask) or close contact with someone awaiting results for or diagnosed with COVID-19? *

Yes

Have you traveled internationally or outside of state in the last 14 days? *

Yes

Stage 1 Screening

If you ave experienced any two of these symptoms, or you have a temperature of 100.4 F, please do not report to your work location. Self-isolate at home and contact your primary physician for further direction. Please contact your immediate supervisor for guidance regarding leave requests.
You should self-isolate at home for a minimum of 14 days since the start of symptoms.
You must have 3 days without fevers and improvement in respiratory symptoms.

If you are experiencing severe or life-threatening symptoms, please call 911.

Temperature Reading

A copy of your responses will be emailed to the address you provided.

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