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
1. Have you washed your hands or used antiseptic before entering?
No (please do so upon entering)
2. Which of the following symptoms do you have?
Shortness of breath
Persistent pain in the chest
Muscle or body aches
New loss of taste or smell
Congestion or runny nose
Nausea or vomiting
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?
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
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