Employee COVID-19 Self Screening Questionnaire

You must answer “NO” to all the questions in this questionnaire in order to service a client or enter our office location. If you answer “YES” to any of the questions, please DO NOT come to the office or present at any client's home(s).

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 management.

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

	Yes	No
Cough
Shortness of breath of difficulty breathing

OR any of the following symptoms in the last 24 hours:*

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

If you answered “Yes” to question one, please DO NOT come into work. You should:
- Immediately get a COVID-19 test. If result is positive you should immediately alert management and self-quarantine for at least 10 days from the date on which you first experienced any of the above symptoms; AND
- After your 10 days have passed get another COVID-19 test to show you are negative and no longer a risk to others. And have
- Improved respiratory symptoms (no cough, shortness of breath)
- If your test is negative and you no longer have any symptoms (fever, coughing, shortness of breath)you may return to work.

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 internationally or taken a cruise

If you answered “Yes” to any part of question two, please DO NOT come into work. You should self quarantine for at least 14 days or present a negative COVID-19 test.

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

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Name*

First NameLast Name
Date*

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Date
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