COVID-19 Health Screening
Please answer the following questions honestly
Have you experienced any of the following symptoms in the past 48 hours: Fever (100 degrees or higher),chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea
Within the past 14 days, have you been in close physical contact (6 feet or closer for at least 15 minutes) with a person who is known to have laboratory-confirmed COVID-19 or with anyone who has any symptoms consistent with COVID-19?
What is your temperature?
What client are you scheduled to stay with this shift?
Date of shift
Should be Empty: