Employee COVID-19 Self Screening Questionnaire

Employee COVID-19 Self Screening Questionnaire

Signature required, needs to signed on smart phone or tablet.
There has been new guidance from the CDC on possible symptoms. Please review the questions carefully and answer appropriately.

1) Any of combination the following symptoms in the last 24 hours: *

To comply with safety standards to protect you, the client, and involved others, we require that employees, clients, and those who reside with the client are Covid-19 symptom-free. Please complete and submit this form on days that clients and employees work together in person.

You must answer “NO” to all the questions in this questionnaire for an employee to work with the H.A.T.C.H. client.
If you answered “Yes” to any of the questions, please DO NOT report to work. You should:
- Contact the client, family, facility, or supportive living staff to let them know that you will be unable to work.
- Contact your doctor and follow their health orders. If they have determined that you or someone in your household is Covid-19 positive, you should do the following:
- 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
Been in contact with someone who was diagnosed with COVID-19?

If you answered “Yes” to any part of question two, please DO NOT report to work if you are doing in-person services. You should self-quarantine for at least 10 days.
3) Are you wearing a properly fitting mask that covers both your nose and your mouth? *

Yes No
Please contact the H.A.T.C.H. office if you need additional personal protective equipment.
Are there any chronic conditions that present as similar symptoms such as a headaches, chills, or a cough? We do not need any chronic conditions disclosed, we are checking for new or unusual symptoms directly related to COVID-19. Please contact H.A.T.C.H. to discuss further if needed. *

Yes No
4) Today's body temperature: *
I declare to the best of my knowledge; this information is accurate.
Signature *

Clear
Name *

First Name Last Name
Date *

Month Day Year
Should be Empty: