COVID-19 Workplace Health Screen

Employee Name*

Employee Number*

Date/Time:

In the Past 24 hours, have you experienced any of the below symptoms? Select all boxes that apply.*

Subjective fever (felt feverish)
New or worsening cough
Shortness of Breath
Sore Throat
Vomiting/Diarrhea
None of the above

Have you had close contact in the last 14 days win an individual diagnosed with COVID-19*

Have you engaged in any activity or travel within the last 14 days which would put you at higher risk?*

Have you been directed to or told by the local health department or your healthcare provider to self-isolate or self-quarantine?*

Because you have answered yes to one or more of the questions above please do not go into the building and report to your Manager, or HR for further instruction.

Signature*

COVID-19 Workplace Healthscreen

Gaylord

Clare