Employee Health Self Assessment

Precision Temperature Inc.

11974 Woodside Ave | Lakeside, CA 92040

619-588-5321 | info@ptempinc.com
Employee Health Self Assessment
You must answer “NO” to all the questions in this questionnaire in order to work today.

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 your manager and HR.

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

Rows	Yes	No
Cough
Shortness of breath of difficulty breathing

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

Rows	Yes	No
Fever (usually 100.4 or higher)
Chills
Repeated shaking with chills
Muscle pain
Headache
Sore throat
New loss of taste or smell

In the last 14 days have you:

Rows	Yes	No
Are you currently waiting on results of a COVID-19 Test?
Are you currently positive for COVID-19?

What is your current body temperature?
Time this form was completed

:HourMinutesAM/PM Option
If you answered “Yes” to question any of the above, please finish and submit this form and DO NOT come into work. You must immediately contact your health care professional for recommended next steps AND notify your manager and HR.

Beginning of the day:

Rows	Yes	No
Do you currently have any medical condition that may impair you driving a company vehicle?
Have you performed your 8-12 minutes beginning of day stretch and flex exercises (this should be on the clock)?

If you answered “Yes” to impair driving , please DO NOT operate any company vehicle. Please contact your health care professional if needed AND notify your manager and HR.

Please note that the company has allocated the first 15 minutes of your morning shift to complete your beginning of the day strectch and flex exercises and complete this form.

I certify to the best of my knowledge; this information is accurate.
Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Should be Empty: