• Staff Health Screening for COVID-19

  • This form should be completed BEFORE entering a location prior to the start of your shift. **IF yes to any symptoms, you will be sent home and your supervisor will contact you with further instructions. A fever is considered a temperature of 100.4 degrees or higher**


  •  -  -
    Pick a Date
  • While the questions above inquire about the most common symptoms associated with COVID-19, checking “yes” to any of theses is not considered as diagnostic for COVID-19; however, employees should be aware of these other related symptoms which should be monitored.

  • Clear
  •  -  -
    Pick a Date
  • Should be Empty:
Jotform Logo
Now create your own JotForm - It's free! Create your own JotForm