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CCSC Covid-19 CIW Screening
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* Indicates required question
Employee Name
*
Your answer
Today's Date
*
MM
/
DD
/
YYYY
Employee School
*
CHS
CMS
Hoover
Nicholson
Hose
Willson
West Central
Other
Have you experienced any of these symptoms in the last 24 hours?
*
Fever or Chills
Cough
Shortness of Breath
Fatigue
Headache
New Loss of Taste or Smell
Sore Throat
Congestion or Runny Nose
Nausea or Vomitting
Diarrhea
Muscle or Body Aches
No Symptoms in the last 24 hours
Required
Are you currently waiting on results of a COVID-19 test?
*
yes
no
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