COVID-19 SCREENING

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, they should not report to work.)

First Name

Last Name

Shift:

A new fever (100.4°F or higher) or a sense of having a fever?

A new cough that cannot be attributed to another health condition?

New shortness of breath that cannot be attributed to another health condition?

New chills that cannot be attributed to another health condition?

A new sore throat that cannot be attributed to another health condition?

New muscle aches (myalgia) that cannot be attributed to another health condition or specific activity (such as physical exercise)?

A new loss of taste or smell?

A positive test for the virus that causes COVID-19 disease within the past 14 days?

Close contact (within about 6 feet for 15 minutes or more) with someone with suspected or confirmed COVID-19 in the past 14 days?

International travel in the past 14 days?