COVID-19 Daily Workplace Health Employee Self-Screening
This form is to be completed daily
Employee ID
*
Employee ID (this is the same username you use for TimeTracker)
Date
*
-
Month
-
Day
Year
Date
Have you tested positive for COVID-19 within the past 14 days?
*
Yes
No
Have you knowingly been exposed to an individual with a confirmed or suspected case of COVID-19 within the past 14 days?
*
Yes
No
Have you been asked to self-isolate or quarantine by a medical professional or public health official within the past 14 days?
*
Yes
No
Are you currently experiencing any of these symptons (excluding those known to be caused by a medical reason other than COVID-19)?
*
Fever (100.4 or greater) or chills
Cough
Shorness of breath or difficulty breathing
New loss of taste or smell
Sore Throat
Vomiting or Diarrhea
None of the above
Current Temperature
*
Current Body Temperature
Signature
Submit
Should be Empty: