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Please fill out the questions in the form. If you mark yes to any of the questions, please contact your supervisor before reporting to work.
7
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1
Please enter today's date:
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Date
Year
Month
Day
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2
Please enter your first and last name:
First Name
Last Name
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3
Email:
example@example.com
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4
In the past 72 hours, have you or anyone in your household experienced any of the following?
Fever
Cough
Shortness of breath or difficulty breathing
Headache
Sore throat
Loss of taste or smell
Diarrhea
Fever greater than or equal to 100 degrees
Weakness and fatigue
Tiredness
None of the above
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5
Have you or anyone in your household recently been in contact with anyone who has exhibited any of the previous mentioned symptoms?
YES
NO
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6
Have you or anyone in your household recently (preceding 14 days) been in close contact with anyone who has been lab-confirmed positive for COVID-19?
YES
NO
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7
Have you or anyone in your household recently traveled outside the United States in the past 14 days?
YES
NO
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8
In the past 14 days, have you attended a large gathering of more than 10 people where you were in close proximity to other people who were not wearing masks?
YES
NO
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COVID-19 Questionnaire
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