Screening Questions: Please answer Yes/No to each question

Screening Questions: Please answer Yes/No to each question
If you answer yes to any questions, leave work immediately. Please notify your supervisor and the Office of Human Resources for guidance at 255-5514.
Employee Name*
1-Do you have a fever (above 100F)*

YesNo
2-Have you had COVID-19 symptoms within the past 14 days?
- Cough
- Shortness of breath or difficulty breathing
- Fever
- Chills
- Muscle pain
- Sore throat
- New loss of taste or smell
YesNo
3-Have you had a positive COVID-19 test within the past 14 days?*

YesNo
4-Have you have close contact with confirmed or suspected COVID-19 cases within the past 14 days?*

YesNo
Should be Empty: