DDS REQUIRED QUESTIONS

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**
Name *

First Name Last Name
Work Location *
What is your current temperature? *
Have you had a fever? *

Yes No
Are you experiencing a cough, shortness of breath, general fatigue, headache, chills, loss of taste, or muscle aches? *

Yes No
In the last 24 hours, have you experienced any generalized abdominal pain? *

Yes No
Have you experienced or are you experiencing vomiting/diarrhea? *

Yes No
If you've answered "Yes" to any of the questions above, please add the date the symptoms started.

Month Day Year
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.
In the last 14 days, have you come into close contact (closer than 6 ft for 15 minutes or longer) with a person whom you know either has COVID-19 or has exhibited symptoms of COVID-19?

Yes No
Have you been in another state on the CT travel ban list since your last check in? If yes, please notify the human resource director immediately.

Yes No
In the last 14 days, have you been on a plane/train/cruise ship; traveled outside of CT? *

Yes No
Within the last 14 days, have you been directed or ordered by a health care provider, government entity or other employer to self-quarantine or isolate because of a possible COVID-19 exposure or test result?

Yes No
If you have traveled, please list the location.
Comments:
Signature

Clear
Date

Month Day Year
Date
Should be Empty:

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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**

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