Employee COVID-19 Self Screening Questionnaire

You must answer “NO” to all the questions in this questionnaire in order to enter and work at ESSpa today. If you answer “YES” to any of the questions, please DO NOT come to work or enter the building.

If you experience any symptoms or answer “YES” to any of these questions, you must immediately notify Eva+Scott+manager AND contact your health care professional for recommended next step(s).

Your Temperature today?

enter the temperature when you arrived at work today.

Have you received the Covid19 Vaccination?

Yes No Scheduled Will not get

Have you had any of the following symptoms in the last 24 hours: *

Yes

No

Fever (100.1 or higher Temp)

Cough

Unexpected Tiredness

Muscle pain

Headache

Sore throat

Loss of taste or smell

Nausea

Chills

Shortness of Breath

If you answered “Yes” to any questions above, please call Eva+Scott immedately for further instructions. You might be asked to:

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?

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

Traveled outside PA in the past 10 days?

Attended any gathering with 15+ individuals in last 10 days?

Been referred to take a Covid19 Test or have a test pending?

Recently visited any bar, club or "unmasked" establishment?

Do you live or spend time with anyone who has a pending test for Covid19?

If you answered “Yes” to any part of question two, please Alert your Manager immediately. You might be required to self quarantine for at least 14 days.

I am providing this personal linformation willfully and without coercion. By my signature below, I confirm that all information herein is truthful and accurate. I acknowledge and hereby indemnify, waive and release ESSpa, its owners and managers from any and all liability as may relate to any unintentional exposure or harm due to Covid-19.

Signature *

Clear

Name *

First Name Last Name

Date *

Date

ESSPA Employee COVID-19 Questionnaire