Employee Illness Self Screening Questionnaire

Employee Illness Self Screening Questionnaire

Employee Illness Self Screening Questionnaire
Name*

First NameLast Name
Email
If you would like email confirmation of your submission
Location*
Date*

MonthDayYear
Date
Question 1

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

	Yes	No
Fever or 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

If you answer “YES” to any part of question 1, please DO NOT enter the company’s buildings. Notify your manager and HR, and await further instructions.
Question 2

2) In the last 14 days have you:*

	Yes	No
Been in contact with someone who was diagnosed with COVID-19, Norovirus, or any other respiratory illness?
Been in close contact with someone who has been diagnosed with any type of Influenza?
Traveled internationally or taken a cruise

If you answered “Yes” to any part of question two, please DO NOT come into the company’s buildings. Contact your manager & HR for further instructions.
I certify to the best of my knowledge, this information is accurate.

If the answer to any of the questions is YES, I will follow the instructions as stated above.
Signature*

Clear
Manager Email
example@example.com
Should be Empty: