COVID-19 Daily Health Checklist
DON'T FORGET TO CHECK YOUR TEMPERATURE WHEN YOU ARRIVE AT WORK!
Name
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First Name
Last Name
Are you experienced any symptoms of COVID-19? Symptoms include: fever, shortness of breath, cough, chills, shaking, muscle pain, headache, sore throat, new loss of taste or smell.
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Yes
No
Have you knowingly been in close or proximate contact in the past 14 days with anyone who has tested positive for COVID-19 or who has or had symptoms of COVID-19?
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Yes
No
Have you tested positive for COVID-19 in the past 14 days?
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Yes
No
Have you traveled out of the country OR to any of the following states in the last 14 days? *RESTRICTED STATES UPDATED 09/23/20 Alabama, Alaska, Arkansas, Arizona, Delaware, Florida, Georgia, Guam, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, North Carolina, North Dakota, Oklahoma, Puerto Rico, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, Wisconsin, Wyoming
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Yes
No
By entering my initials below, I certify the answers in the above questions. At any time, if I start showing these symptoms, I will inform my supervisor immediately.
INITIAL HERE
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Submit
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