Employee COVID-19 Self Screening Questionnaire

Employee COVID-19 Self Screening Questionnaire

Signature required, needs to signed on smart phone or tablet.
You must answer “NO” to all the questions in this questionnaire each day in order to work with H.A.T.C.H. clients. If you answer “YES” to any of these questions, please notify the client, the client's family, or the facility in which the client resides in.

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 H.A.T.C.H.

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

Yes

Cough

Shortness of breath of difficulty breathing

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

Yes

Fever (usually 100.4 or higher)

Chills

Repeated shaking with chills

Muscle pain

Headache

Sore throat

New loss of taste or smell

If you answered “Yes” to question one, 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

Been in contact with someone who was diagnosed with COVID-19?

Been in close contact with someone who had COVID-19 symptoms ?

Traveled internationally or taken a cruise

If you answered “Yes” to any part of question two, please DO NOT allow the H.A.T.C.H. employee to come into work. You should self-quarantine for at least 14 days.
Are there any chronic conditions that present as similar symptoms such as a headaches, chills, or a cough? We are checking for new or unusual symptoms. Please contact H.A.T.C.H. to discuss further if needed. *

Yes No
3) Today's body temperature: *
I certify to the best of my knowledge; this information is accurate.
Signature (needs to be signed on smart phone or tablet) *

Clear
Name *

First Name Last Name
Date *

Month Day Year
Should be Empty: