Employee COVID-19 Self Screening Questionnaire

Are you fully vaccinated against COVID-19?

NoYes

You must answer “NO” to all the below questions in this questionnaire in order to enter our physical location. If you answer “YES” to any of the below questions, please DO NOT come enter the company’s buildings.

If you experience any symptoms or answer “YES” to any of these questions, you must immediately contact your health care professional for recommended next steps AND notify your manager and HR.

1A Have you had any of the following symptoms in the last 24 hours?*

	Yes	No
Cough
Shortness of breath of difficulty breathing
Fever (usually 100.4 or higher)

OR 1B at least TWO of the following symptoms in the last 24 hours: * *

	Yes	No
Chills
Repeated shaking with chills
Muscle Pain
Headache
Sore Throat
New loss of taste or smell

Calculation to 1B

Calculation to contact tracing

If you answered “Yes” to question 1A or two yes answers to 1B, please DO NOT come into work. You should:

Self-quarantine for at least 10 days from the date on which you first experienced any of the above symptoms; AND
Wait until you have had no fever for at least 3 days (without the use of fever-reducing medication) AND
Improved respiratory symptoms (no cough, shortness of breath)

2) In the last 14 days have you:*

	Yes	No
Have you experienced any symptoms of COVID-19 in the past 14 days?
Have you tested positive for COVID-19?

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?*

NoYes

Link to NY.GOV's list of restricted states: https://coronavirus.health.ny.gov/covid-19-travel-advisory

I certify to the best of my knowledge; this information is accurate.

Signature*

Name*

First NameLast Name

Date*

Date