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COVID-19 Screening Protocol: Employee self-check of health
Please fill out this form before the beginning of your shift.
YES or NO since my last day of work have I had any of the following:
(
If an employee answers YES
to any of the screening questions before reporting to work, should not report to work. )
Name
(Required)
Shift working:
A new fever (100.4°F or higher) or a sense of having a fever?
(Required)
Yes
No
A new cough that cannot be attributed to another health condition?
(Required)
Yes
No
New shortness of breath that cannot be attributed to another health condition?
(Required)
Yes
No
New chills that cannot be attributed to another health condition?
(Required)
Yes
No
A new sore throat that cannot be attributed to another health condition?
(Required)
Yes
No
New muscle aches (myalgia) that cannot be attributed to another health condition or specific activity (such as physical exercise)?
(Required)
Yes
No
A new loss of taste or smell?
(Required)
Yes
No
A positive test for the virus that causes COVID-19 disease within the past 14 days?
(Required)
Yes
No
Close contact (within about 6 feet for 15 minutes or more) with someone with suspected or confirmed COVID-19 in the past 14 days?
(Required)
Yes
No
International travel in the past 14 days?
(Required)
Yes
No
Submit
Thank you for completing the Employee Self-Check of Health form.
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