1) Did you check for a temperature over 100 before your shift and again during the day? Yes   No  

2) Have you had any of the following symptoms in the last 24 hours?
Yes   No   Fever or chills
Yes   No   Cough
Yes   No   Shortness of breath or difficulty breathing
Yes   No   Fatigue
Yes   No   Muscle or body aches
Yes   No   Headache
Yes   No   New loss of taste or smell
Yes   No   Sore throat
Yes   No  Congestion or runny nose
Yes   No   Nausea or vomiting
Yes   No  Diarrhea

3) Have you been advised or ordered to quarantine or isolate by a health care provider or a governmental agency, or have you been on a cruise in the last 14 days?
Yes   No   

4) Have you been within 6 feet or had direct contact with infectious secretions or excretions (e.g. coughed on, touching tissue with bare hand) of anyone diagnosed with COVID-19 in the past 14 days without appropriate protection?
Yes   No