Screening Checklist for Visitors and Employees
Please answer all questions to the best of your knowledge before entering the building. If you exhibit any symptoms or have been exposed to COVID-19 please do not enter and quarantine yourself for a minimum of 14 days.
Name of the Individual
*
Phone Number
*
-
Area Code
Phone Number
Email
example@example.com
1. Have you washed your hands or used antiseptic before entering?
*
Yes
No (please do so upon entering)
2. Which of the following symptoms do you have?
*
Fever
Cough
Shortness of breath
Persistent pain in the chest
Fatigue
Muscle or body aches
Headache
New loss of taste or smell
Sore throat
Congestion or runny nose
Nausea or vomiting
Diarrhea
None
3. Please check your temperature and enter the result in degrees Fahrenheit.
*
4. Have you had contact with people that were infected, suspected or diagnosed with COVID-19 in the past month?
*
Yes
No
I don't know
5. Additional Notes/ Explanation of Symptoms
Reminder to please:
Wash hands (with hot soapy water for at least 20 seconds) or use antiseptics
Not shake hands or have any contact physically with others outside of your household
Wear facemasks in the building at all times
Keep at least 6 feet apart from others outside of your household
Submit
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