Screening Checklist for Visitors and Employees

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Name of the Individual
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2. Please Check any of the symptoms or conditions that you have
Fever In the Last 14 Days
Cough
Shortness of Breath
Persistent Pain in the Chest
Flu Like Symptoms, sug as GI upset, Headache or Fatigue
Recent Loss of Taste or Smell
Have you been in Contact with a confirmed COVID-19 Patient in the last 14 days
Do You have any Heart Disease, Lung Disease, Kidney Disease, Diabetes, or any auto-immune disorders?
Have you traveled out of the St Louis Metropolitan Area in the last 14 days?
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3. For employees - check the temperature and enter the result.
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Hand Santizer will be provided when you enter the office.

If you are wearing gloves, we ask that you remove them and wash your hands, we will not allow outside gloves in the office.

We will also have you rinse with an anti viral for 60 seconds
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Signature
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